Healthcare Provider Details

I. General information

NPI: 1891826368
Provider Name (Legal Business Name): TULSA PEDIATRIC GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6465 S YALE AVE STE 715
TULSA OK
74136-7809
US

IV. Provider business mailing address

6465 S YALE AVE STE 715
TULSA OK
74136-7809
US

V. Phone/Fax

Practice location:
  • Phone: 918-481-4750
  • Fax: 918-481-4755
Mailing address:
  • Phone: 918-481-4750
  • Fax: 918-481-4755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9951
License Number StateOK

VIII. Authorized Official

Name: KRISTIN M STEVENS
Title or Position: OWNER
Credential: M.D.
Phone: 918-481-4750