Healthcare Provider Details

I. General information

NPI: 1629067962
Provider Name (Legal Business Name): DIANE M HEATON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S UTICA AVE
TULSA OK
74104-4012
US

IV. Provider business mailing address

PO BOX 21228 DEPT. 18
TULSA OK
74121
US

V. Phone/Fax

Practice location:
  • Phone: 918-579-8215
  • Fax: 918-579-8204
Mailing address:
  • Phone: 918-579-8204
  • Fax: 918-579-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number18768
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: