Healthcare Provider Details

I. General information

NPI: 1962747444
Provider Name (Legal Business Name): FOOT & ANKLE SURGEONS OF OKLAHOMA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 S WESTERN AVE #4020
OKLAHOMA CITY OK
73109-3447
US

IV. Provider business mailing address

PO BOX 268996
OKLAHOMA CITY OK
73126-8996
US

V. Phone/Fax

Practice location:
  • Phone: 405-418-4500
  • Fax: 405-418-4501
Mailing address:
  • Phone: 405-418-4500
  • Fax: 405-418-4501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number290
License Number StateOK

VIII. Authorized Official

Name: CHRISTOPHER J. GREEN
Title or Position: PRESIDENT
Credential: DPM
Phone: 405-418-4500