Healthcare Provider Details

I. General information

NPI: 1326189572
Provider Name (Legal Business Name): LICHAO ZHAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 STANTON L. YOUNG BLVD BMS - 451
OKLAHOMA CITY OK
73104-5042
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 405-271-1515
  • Fax: 405-271-1001
Mailing address:
  • Phone: 405-271-1515
  • Fax: 405-271-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number25003
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number25003
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: