Healthcare Provider Details

I. General information

NPI: 1215136809
Provider Name (Legal Business Name): MILTON R SHEPPARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 S BOULDER AVE
TULSA OK
74119-5234
US

IV. Provider business mailing address

1611 S MAIN ST APT 329
TULSA OK
74119-4443
US

V. Phone/Fax

Practice location:
  • Phone: 918-585-1213
  • Fax: 918-585-1263
Mailing address:
  • Phone: 918-585-1213
  • Fax: 918-585-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: