Healthcare Provider Details

I. General information

NPI: 1629386529
Provider Name (Legal Business Name): VEIN CARE CENTER OF OKLAHOMA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6151 S YALE AVE SUITE 1-302
TULSA OK
74136-1907
US

IV. Provider business mailing address

6151 S YALE AVE SUITE 1-302
TULSA OK
74136-1907
US

V. Phone/Fax

Practice location:
  • Phone: 918-502-3600
  • Fax: 918-502-3610
Mailing address:
  • Phone: 918-502-3600
  • Fax: 918-502-3610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number20034
License Number StateOK

VIII. Authorized Official

Name: DR. ROBERT B. MAMMANA
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 918-502-3600