Healthcare Provider Details

I. General information

NPI: 1194082925
Provider Name (Legal Business Name): MICHAEL LAWRENCE MAGGUILLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 STANTON L YOUNG BLVD # 451
OKLAHOMA CITY OK
73104-5020
US

IV. Provider business mailing address

1122 NE 13TH ST # ORI236
OKLAHOMA CITY OK
73117-1039
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-1515
  • Fax: 405-271-1001
Mailing address:
  • Phone: 405-271-1515
  • Fax: 405-271-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number276817
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: