Healthcare Provider Details

I. General information

NPI: 1285798793
Provider Name (Legal Business Name): JOHN RAIZEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 SPENCER RD
SPENCER OK
73084-3649
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE SUITE 280
OKLAHOMA CITY OK
73112-5556
US

V. Phone/Fax

Practice location:
  • Phone: 405-427-2441
  • Fax: 405-427-4741
Mailing address:
  • Phone: 405-427-2441
  • Fax: 405-427-4741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number19490
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: