Healthcare Provider Details

I. General information

NPI: 1083609861
Provider Name (Legal Business Name): GARY W BREIPOHL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9423 E 95TH CT
TULSA OK
74133-5805
US

IV. Provider business mailing address

DEPT 1654
TULSA OK
74182-0001
US

V. Phone/Fax

Practice location:
  • Phone: 918-496-2400
  • Fax: 405-948-6507
Mailing address:
  • Phone: 405-947-8585
  • Fax: 405-948-6507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number16657
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number54361
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: