Healthcare Provider Details

I. General information

NPI: 1326063017
Provider Name (Legal Business Name): CHARLES PAUL MIRABILE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 W MEMORIAL RD STE 321
OKLAHOMA CITY OK
73120
US

IV. Provider business mailing address

4140 W MEMORIAL RD STE 321
OKLAHOMA CITY OK
73120-8300
US

V. Phone/Fax

Practice location:
  • Phone: 405-748-4726
  • Fax: 405-607-8497
Mailing address:
  • Phone: 405-748-4726
  • Fax: 405-607-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number20629
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: