Healthcare Provider Details

I. General information

NPI: 1679668552
Provider Name (Legal Business Name): KATHLEEN LOREE CARLSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7614 E 91ST STREET SUITE 100
TULSA OK
74133-6047
US

IV. Provider business mailing address

7614 E 91ST STREET SUITE 100
TULSA OK
74133-6047
US

V. Phone/Fax

Practice location:
  • Phone: 918-495-1144
  • Fax: 918-495-3518
Mailing address:
  • Phone: 918-495-1144
  • Fax: 918-495-3518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number11624
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: