Healthcare Provider Details

I. General information

NPI: 1417166802
Provider Name (Legal Business Name): CHILDRENS CLINIC OF OWASSO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8439 N 117TH EAST AVE
OWASSO OK
74055-2142
US

IV. Provider business mailing address

8439 N 117TH EAST AVE
OWASSO OK
74055-2142
US

V. Phone/Fax

Practice location:
  • Phone: 918-272-8989
  • Fax: 918-272-4185
Mailing address:
  • Phone: 918-272-8989
  • Fax: 918-272-4185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3442
License Number StateOK

VIII. Authorized Official

Name: DR. CHERYL A BOYD
Title or Position: OWNER
Credential: D,O,
Phone: 918-272-8989