Healthcare Provider Details

I. General information

NPI: 1215920293
Provider Name (Legal Business Name): SOUTH TULSA PEDIATRICS PLLJ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7512 E 91ST ST
TULSA OK
74133-6050
US

IV. Provider business mailing address

7512 E 91ST ST
TULSA OK
74133-6050
US

V. Phone/Fax

Practice location:
  • Phone: 918-728-2000
  • Fax: 917-728-2000
Mailing address:
  • Phone: 918-728-2000
  • Fax: 917-728-2000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2732
License Number StateOK

VIII. Authorized Official

Name: DAWN A MAYBERRY
Title or Position: OWNER/PHYSICIAN
Credential: D.O.
Phone: 918-728-2888