Healthcare Provider Details

I. General information

NPI: 1710417092
Provider Name (Legal Business Name): PRASHANTH S IYER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 S WHEELING AVE STE 105
TULSA OK
74104-5638
US

IV. Provider business mailing address

1265 S UTICA AVE STE 300
TULSA OK
74104-4243
US

V. Phone/Fax

Practice location:
  • Phone: 918-749-6400
  • Fax: 918-749-2168
Mailing address:
  • Phone: 918-592-0999
  • Fax: 918-592-1021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number39831
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: