Healthcare Provider Details

I. General information

NPI: 1518028125
Provider Name (Legal Business Name): EAR NOSE & THROAT CLINIC OF TULSA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 S HARVARD AVE #100
TULSA OK
74135-2634
US

IV. Provider business mailing address

4444 S HARVARD AVE #100
TULSA OK
74135-2634
US

V. Phone/Fax

Practice location:
  • Phone: 918-744-0228
  • Fax: 918-744-6613
Mailing address:
  • Phone: 918-744-0228
  • Fax: 918-744-6613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: C KATHLEEN WORRALL
Title or Position: OFFICE ADMINISTRATION
Credential:
Phone: 918-744-0228