Healthcare Provider Details

I. General information

NPI: 1356544951
Provider Name (Legal Business Name): KRISTIN DIANE CONKLING MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5125 E 107TH PL
TULSA OK
74137-7236
US

IV. Provider business mailing address

5125 E 107TH PL
TULSA OK
74137-7236
US

V. Phone/Fax

Practice location:
  • Phone: 254-718-8654
  • Fax:
Mailing address:
  • Phone: 254-718-8654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number19804
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: