Healthcare Provider Details

I. General information

NPI: 1154483303
Provider Name (Legal Business Name): HAROLD M GINZBURG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE DEPT OF PSYCHIATRY
TAHLEQUAH OK
74464-2512
US

IV. Provider business mailing address

100 S BLISS AVE DEPT OF PSYCHIATRY
TAHLEQUAH OK
74464-2512
US

V. Phone/Fax

Practice location:
  • Phone: 504-858-0066
  • Fax: 504-613-4913
Mailing address:
  • Phone: 504-858-0066
  • Fax: 504-613-4913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number25865
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25865
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier99610
Identifier TypeMEDICAID
Identifier StateLA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: