Healthcare Provider Details

I. General information

NPI: 1891891305
Provider Name (Legal Business Name): LISA DANELE TAYLOR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4514 MEMORIAL CIR SUITE B
OKLAHOMA CITY OK
73142-5000
US

IV. Provider business mailing address

4514 MEMORIAL CIR SUITE B
OKLAHOMA CITY OK
73142-5000
US

V. Phone/Fax

Practice location:
  • Phone: 405-751-1321
  • Fax: 405-755-3708
Mailing address:
  • Phone: 405-751-1321
  • Fax: 405-755-3708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number17865
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: