Healthcare Provider Details

I. General information

NPI: 1730484098
Provider Name (Legal Business Name): CORDELL LEWIS CM1
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 N KELLEY AVE SUITE100
OKLAHOMA CITY OK
73111-4520
US

IV. Provider business mailing address

9819 SKYLARK RD
OKLAHOMA CITY OK
73162-5661
US

V. Phone/Fax

Practice location:
  • Phone: 405-524-5525
  • Fax:
Mailing address:
  • Phone: 405-621-5952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number23106
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: