Healthcare Provider Details

I. General information

NPI: 1992773188
Provider Name (Legal Business Name): KEITH L STANLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 S 109TH EAST AVE
TULSA OK
74146-5822
US

IV. Provider business mailing address

4802 S 109TH E AVENUE
TULSA OK
74146
US

V. Phone/Fax

Practice location:
  • Phone: 918-392-1400
  • Fax: 918-392-1488
Mailing address:
  • Phone: 918-392-1400
  • Fax: 918-392-1488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number15232
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: