Healthcare Provider Details

I. General information

NPI: 1831146851
Provider Name (Legal Business Name): WALLACE ROY PRATT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 KETHLEY RD
SHAWNEE OK
74804-9638
US

IV. Provider business mailing address

PO BOX 258884
OKLAHOMA CITY OK
73125-8884
US

V. Phone/Fax

Practice location:
  • Phone: 405-273-5801
  • Fax: 405-878-3794
Mailing address:
  • Phone: 405-231-3857
  • Fax: 405-272-7977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number18812
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: