Healthcare Provider Details

I. General information

NPI: 1851351969
Provider Name (Legal Business Name): LEROY SOUTHMAYD III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 03/08/2020
Certification Date: 03/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 W WILSHIRE BLVD
OKLAHOMA CITY OK
73116-6109
US

IV. Provider business mailing address

1202 W WILSHIRE BLVD
OKLAHOMA CITY OK
73116-6109
US

V. Phone/Fax

Practice location:
  • Phone: 405-823-3073
  • Fax:
Mailing address:
  • Phone: 405-823-3073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number17164
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: