Healthcare Provider Details

I. General information

NPI: 1861071888
Provider Name (Legal Business Name): PHILIP LOYD RIDGWAY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 SOUTHWEST BLVD
TULSA OK
74107-2705
US

IV. Provider business mailing address

5310 E 31ST ST STE 13
TULSA OK
74135-5013
US

V. Phone/Fax

Practice location:
  • Phone: 918-561-1131
  • Fax: 918-561-1140
Mailing address:
  • Phone: 918-561-5701
  • Fax: 918-561-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number7657
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: