Healthcare Provider Details

I. General information

NPI: 1215960810
Provider Name (Legal Business Name): KATHY L STUBBS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 E. CLEVELAND
SAPULPA OK
74066
US

IV. Provider business mailing address

PO BOX 400
OKMULGEE OK
74447-0400
US

V. Phone/Fax

Practice location:
  • Phone: 918-224-9310
  • Fax: 918-756-3993
Mailing address:
  • Phone: 918-756-3334
  • Fax: 918-756-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2553
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: