Healthcare Provider Details

I. General information

NPI: 1720073133
Provider Name (Legal Business Name): BRIAN RIBAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 E 19TH ST SUITE 400
TULSA OK
74104-5425
US

IV. Provider business mailing address

1802 E 19TH ST SUITE 400
TULSA OK
74104-5425
US

V. Phone/Fax

Practice location:
  • Phone: 918-748-7644
  • Fax: 918-293-3184
Mailing address:
  • Phone: 918-748-7644
  • Fax: 918-293-3184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number11245
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: