Healthcare Provider Details

I. General information

NPI: 1699236307
Provider Name (Legal Business Name): SOUTH TULSA RETINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9940 E 81ST ST
TULSA OK
74133-4501
US

IV. Provider business mailing address

9940 E 81ST ST
TULSA OK
74133-4501
US

V. Phone/Fax

Practice location:
  • Phone: 918-893-9240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTY PHILLIPS
Title or Position: DIRECTOR OF BUSINESS AFFAIRS
Credential:
Phone: 918-893-9240