Healthcare Provider Details

I. General information

NPI: 1003094665
Provider Name (Legal Business Name): CORY BRIT KEBERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S UTICA AVE STE A
TULSA OK
74104-5346
US

IV. Provider business mailing address

1004 E BRYAN AVE
SAPULPA OK
74066-4513
US

V. Phone/Fax

Practice location:
  • Phone: 981-748-7557
  • Fax: 918-748-7514
Mailing address:
  • Phone: 918-748-7557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number26794
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: