Healthcare Provider Details

I. General information

NPI: 1265524953
Provider Name (Legal Business Name): WATERFORD PLASTIC SURGERY CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6305 WATERFORD BLVD STE 115
OKLAHOMA CITY OK
73118-1116
US

IV. Provider business mailing address

6305 WATERFORD BLVD STE 115
OKLAHOMA CITY OK
73118-1116
US

V. Phone/Fax

Practice location:
  • Phone: 405-848-3459
  • Fax: 405-848-5401
Mailing address:
  • Phone: 405-848-3459
  • Fax: 405-848-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number22456
License Number StateOK

VIII. Authorized Official

Name: JUSTIN M JONES
Title or Position: PRESIDENT
Credential: MD
Phone: 405-848-3459