Healthcare Provider Details

I. General information

NPI: 1174133615
Provider Name (Legal Business Name): SI YUAN KHOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6465 S YALE AVE STE 804
TULSA OK
74136-7810
US

IV. Provider business mailing address

4640 S ASPEN AVE APT 3311
BROKEN ARROW OK
74011-2164
US

V. Phone/Fax

Practice location:
  • Phone: 918-502-3555
  • Fax:
Mailing address:
  • Phone: 918-494-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4351046215
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number79234
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number46585
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: