Healthcare Provider Details

I. General information

NPI: 1164434585
Provider Name (Legal Business Name): ETHAN D STOLZENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 STANTON L YOUNG BLVD SUITE 451
OKLAHOMA CITY OK
73104-5020
US

IV. Provider business mailing address

1122 NE 13TH ST ORI 236
OKLAHOMA CITY OK
73117-1039
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-2422
  • Fax:
Mailing address:
  • Phone: 405-271-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number25244
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number25244
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: