Healthcare Provider Details

I. General information

NPI: 1073150835
Provider Name (Legal Business Name): MIDTOWN TULSA PEDIATRIC GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2019
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 S HARVARD AVE
TULSA OK
74112-6826
US

IV. Provider business mailing address

2304 S CINCINNATI AVE
TULSA OK
74114-1222
US

V. Phone/Fax

Practice location:
  • Phone: 918-740-1384
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: RYAN DUNLAP
Title or Position: OFFICE MANAGER
Credential:
Phone: 918-740-1384