Healthcare Provider Details

I. General information

NPI: 1992898209
Provider Name (Legal Business Name): DAVID L SHADID DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4612 S HARVARD AVE STE A
TULSA OK
74135-2908
US

IV. Provider business mailing address

4612 S HARVARD AVE STE A
TULSA OK
74135-2908
US

V. Phone/Fax

Practice location:
  • Phone: 918-747-5565
  • Fax: 918-747-5568
Mailing address:
  • Phone: 918-747-5565
  • Fax: 918-747-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2930
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2930
License Number StateOK

VIII. Authorized Official

Name: MR. DAVID L SHADID
Title or Position: PRESIDENT PHYSICIAN
Credential: DO
Phone: 918-747-5565