Healthcare Provider Details

I. General information

NPI: 1285891945
Provider Name (Legal Business Name): KIDS PEDIATRIC AND ADOLESCENT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7711 E 111TH ST SUITE 111
TULSA OK
74133-2570
US

IV. Provider business mailing address

7711 E 111TH ST SUITE 111
TULSA OK
74133-2570
US

V. Phone/Fax

Practice location:
  • Phone: 918-394-5437
  • Fax:
Mailing address:
  • Phone: 918-394-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number13860
License Number StateOK

VIII. Authorized Official

Name: JOHN C KNIPPERS
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 918-394-5437