Healthcare Provider Details

I. General information

NPI: 1124061551
Provider Name (Legal Business Name): GEORGE SHAKER COHLMIA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1373 E BOONE ST SUITE 3400
TAHLEQUAH OK
74464-3364
US

IV. Provider business mailing address

2448 E 81ST ST SUITE 5100
TULSA OK
74137-4248
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-9500
  • Fax: 918-456-9569
Mailing address:
  • Phone: 918-584-2500
  • Fax: 918-584-4634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number15023
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100197620A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: