Healthcare Provider Details

I. General information

NPI: 1114044369
Provider Name (Legal Business Name): STATE OF OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 ROBERT S KERR AVE STE 1702
OKLAHOMA CITY OK
73102-6406
US

IV. Provider business mailing address

123 ROBERT S KERR AVE STE 1702
OKLAHOMA CITY OK
73102-6406
US

V. Phone/Fax

Practice location:
  • Phone: 405-426-8650
  • Fax: 405-900-7498
Mailing address:
  • Phone: 405-426-8650
  • Fax: 405-900-7498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. GITANJALI PAI
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 405-426-8000