Healthcare Provider Details

I. General information

NPI: 1265876494
Provider Name (Legal Business Name): KYLE MOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 S DOUGLAS AVE STE 224
OKLAHOMA CITY OK
73109-3223
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE STE 280
OKLAHOMA CITY OK
73112-5555
US

V. Phone/Fax

Practice location:
  • Phone: 405-644-5447
  • Fax: 405-644-5449
Mailing address:
  • Phone: 405-644-5447
  • Fax: 405-644-5449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number30009
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: