Healthcare Provider Details

I. General information

NPI: 1114340627
Provider Name (Legal Business Name): CERBERUS SURGICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2014
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 E 13TH ST SUITE 200
TULSA OK
74104-4419
US

IV. Provider business mailing address

PO BOX 108819
OKLAHOMA CITY OK
73101-8819
US

V. Phone/Fax

Practice location:
  • Phone: 817-485-5100
  • Fax: 817-485-5101
Mailing address:
  • Phone: 817-485-5100
  • Fax: 817-485-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number200300503
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberK9947
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number23844
License Number StateOK

VIII. Authorized Official

Name: CHARLES NEFF
Title or Position: DIRECTOR
Credential:
Phone: 817-485-5100