Healthcare Provider Details

I. General information

NPI: 1558385740
Provider Name (Legal Business Name): ROSE T GARRETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

IV. Provider business mailing address

1671 NORTH PRIMROSE LANE
TAHLEQUAH OK
74464
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-3355
  • Fax: 918-458-3679
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number027579
License Number StateCT

VII. Legacy identifiers

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

# 1
Identifier150601001
Identifier TypeMEDICAID
Identifier StateAR
Identifier Issuer
# 2
Identifier100213920A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: