Healthcare Provider Details

I. General information

NPI: 1184692360
Provider Name (Legal Business Name): PHILIP C MANTOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 NE 13TH ST JIMMY EVEREST TOWER STE. 2000
OKLAHOMA CITY OK
73104-5008
US

IV. Provider business mailing address

1122 NE 13TH ST ORI236
OKLAHOMA CITY OK
73117-1039
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-2006
  • Fax:
Mailing address:
  • Phone: 405-271-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number16328
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number16328
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number16328
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: