Healthcare Provider Details

I. General information

NPI: 1144218322
Provider Name (Legal Business Name): LAWRENCE CLAY BROTHERTON III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 E 19TH ST SUITE 800
TULSA OK
74104-5472
US

IV. Provider business mailing address

1725 E 19TH ST SUITE 800
TULSA OK
74104-5472
US

V. Phone/Fax

Practice location:
  • Phone: 918-301-2505
  • Fax: 918-744-3633
Mailing address:
  • Phone: 918-301-2505
  • Fax: 918-744-3633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number24398
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: