Healthcare Provider Details

I. General information

NPI: 1205887411
Provider Name (Legal Business Name): MEDICAL PLAZA IMAGING CENTER JOINT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 NW 56TH ST SUITE 206
OKLAHOMA CITY OK
73112-4479
US

IV. Provider business mailing address

3330 NW 56TH ST SUITE 206
OKLAHOMA CITY OK
73112-4479
US

V. Phone/Fax

Practice location:
  • Phone: 405-945-4710
  • Fax: 405-945-4751
Mailing address:
  • Phone: 405-945-4710
  • Fax: 405-945-4751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateOK

VIII. Authorized Official

Name: PAULA J BUTLER
Title or Position: BUSINESS MANAGER
Credential:
Phone: 405-945-4710