Healthcare Provider Details

I. General information

NPI: 1851939326
Provider Name (Legal Business Name): BERRY CHERIYAN THAVALATHIL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BERRY CHERIYAN THAVALATHIL MD

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 05/15/2021
Certification Date: 05/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

IV. Provider business mailing address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

V. Phone/Fax

Practice location:
  • Phone: 405-456-1000
  • Fax:
Mailing address:
  • Phone: 787-653-6060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number21860
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number21860
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: