Healthcare Provider Details

I. General information

NPI: 1992788368
Provider Name (Legal Business Name): ANNIE VENUGOPAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 E 19TH STREET SUITE 501
TULSA OK
74104-5416
US

IV. Provider business mailing address

1705 E 19TH STREET SUITE 501
TULSA OK
74104-5416
US

V. Phone/Fax

Practice location:
  • Phone: 918-744-8110
  • Fax: 918-744-8111
Mailing address:
  • Phone: 918-744-8110
  • Fax: 918-744-8111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number13326
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: