Healthcare Provider Details

I. General information

NPI: 1275251803
Provider Name (Legal Business Name): MAXMILLIAN JOSEPH TJAUW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 08/19/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 STANTON L YOUNG BLVD # 405
OKLAHOMA CITY OK
73104-5018
US

IV. Provider business mailing address

18924 SADDLE RIVER DR
EDMOND OK
73012-4102
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-2316
  • Fax:
Mailing address:
  • Phone: 503-720-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: