Healthcare Provider Details

I. General information

NPI: 1164651394
Provider Name (Legal Business Name): AESTHETIC SURGERY OF TULSA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6802 S OLYMPIA AVE SUITE G113
TULSA OK
74132-1823
US

IV. Provider business mailing address

11913 S SANDUSKY AVE
TULSA OK
74137-1801
US

V. Phone/Fax

Practice location:
  • Phone: 918-960-3033
  • Fax: 918-960-3035
Mailing address:
  • Phone: 918-504-0364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number22998
License Number StateOK

VIII. Authorized Official

Name: ROBERT E MITCHELL
Title or Position: PRESIDENT
Credential: MD
Phone: 918-504-0364