Healthcare Provider Details

I. General information

NPI: 1457796039
Provider Name (Legal Business Name): PEDIATRIC SPECIALISTS OF TULSA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7412 S YALE AVE
TULSA OK
74136-7029
US

IV. Provider business mailing address

7412 S YALE AVE
TULSA OK
74136-7029
US

V. Phone/Fax

Practice location:
  • Phone: 918-523-5437
  • Fax: 918-523-5438
Mailing address:
  • Phone: 918-523-5437
  • Fax: 918-523-5438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21759
License Number StateOK

VIII. Authorized Official

Name: STACY M O'SULLIVAN
Title or Position: OWNER
Credential: MD
Phone: 918-523-5437