Healthcare Provider Details

I. General information

NPI: 1619059466
Provider Name (Legal Business Name): SHANNAN BETH BOND D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 S BRADEN AVE
TULSA OK
74136-6302
US

IV. Provider business mailing address

7251 N 202ND EAST AVE
OWASSO OK
74055-8086
US

V. Phone/Fax

Practice location:
  • Phone: 918-481-8100
  • Fax: 918-481-8159
Mailing address:
  • Phone: 918-272-8867
  • Fax: 918-481-8159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3626
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: