Healthcare Provider Details

I. General information

NPI: 1871733519
Provider Name (Legal Business Name): MJR ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2009
Last Update Date: 02/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 W. 71ST INVERNESS VILLAGE
TULSA OK
74132
US

IV. Provider business mailing address

58 ST ANDREWS CIR
BROKEN ARROW OK
74011-1107
US

V. Phone/Fax

Practice location:
  • Phone: 918-388-4254
  • Fax:
Mailing address:
  • Phone: 918-260-8802
  • Fax: 918-252-0878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number2299
License Number StateOK

VIII. Authorized Official

Name: DR. MARTHA JEAN ROOT
Title or Position: OWNER
Credential: D.O.
Phone: 918-260-8802