Healthcare Provider Details

I. General information

NPI: 1720204761
Provider Name (Legal Business Name): AVALON PARK PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6528 E 101ST ST SUITE D-1, PMB 419
TULSA OK
74133-6724
US

IV. Provider business mailing address

7779 EAST 106TH STREET
TULSA OK
74133-6844
US

V. Phone/Fax

Practice location:
  • Phone: 918-398-7170
  • Fax: 918-398-7199
Mailing address:
  • Phone: 918-398-7170
  • Fax: 918-398-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20582
License Number StateOK

VIII. Authorized Official

Name: DR. DAVID BRIAN RALEY
Title or Position: OWNER
Credential: MD
Phone: 918-398-7170