Healthcare Provider Details

I. General information

NPI: 1386880698
Provider Name (Legal Business Name): RENETTA REEVES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RENETTA BULLARD MD

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S 129TH EAST AVE SUITE 191
TULSA OK
74134-5801
US

IV. Provider business mailing address

4500 S 129TH EAST AVE SUITE 191
TULSA OK
74134-5801
US

V. Phone/Fax

Practice location:
  • Phone: 800-993-8244
  • Fax:
Mailing address:
  • Phone: 800-993-8244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME 62145
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16980
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: