Healthcare Provider Details

I. General information

NPI: 1063945020
Provider Name (Legal Business Name): NAGA SUSHMA CHAVVAKULA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7858 S OLYMPIA AVE
TULSA OK
74132-1857
US

IV. Provider business mailing address

6600 S YALE AVE STE 1400
TULSA OK
74136-3331
US

V. Phone/Fax

Practice location:
  • Phone: 918-986-9200
  • Fax: 918-986-9205
Mailing address:
  • Phone: 918-488-6687
  • Fax: 918-488-6098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35286
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: