Healthcare Provider Details

I. General information

NPI: 1053486431
Provider Name (Legal Business Name): NORTHERN OKLAHOMA REGIONAL PEDIATRIC CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 FAIRVIEW AVE STE. 100
PONCA CITY OK
74601-1923
US

IV. Provider business mailing address

415 FAIRVIEW AVE STE. 100
PONCA CITY OK
74601-1923
US

V. Phone/Fax

Practice location:
  • Phone: 580-765-5569
  • Fax: 580-765-2020
Mailing address:
  • Phone: 580-765-5569
  • Fax: 580-765-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CHRIS W POLLAK
Title or Position: ADMINISTRATOR
Credential:
Phone: 580-765-5569