Healthcare Provider Details

I. General information

NPI: 1578853651
Provider Name (Legal Business Name): LAURA LYNN BODE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 S HOUSTON AVE STE 400
TULSA OK
74127
US

IV. Provider business mailing address

717 S HOUSTON AVE STE 400
TULSA OK
74127-9007
US

V. Phone/Fax

Practice location:
  • Phone: 918-382-4600
  • Fax:
Mailing address:
  • Phone: 918-382-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5185
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: