Healthcare Provider Details

I. General information

NPI: 1083658447
Provider Name (Legal Business Name): MAHMOOD HUSSAIN KHICHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 S YALE AVE PICU
TULSA OK
74136-1902
US

IV. Provider business mailing address

6600 S YALE AVE SUITE 1400
TULSA OK
74136-3347
US

V. Phone/Fax

Practice location:
  • Phone: 918-502-6135
  • Fax:
Mailing address:
  • Phone: 918-488-6001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number18439
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: