Healthcare Provider Details

I. General information

NPI: 1700844453
Provider Name (Legal Business Name): AJIT KURIEN THARAKAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

9228 S MINGO RD SUITE 200
TULSA OK
74133-5718
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number2009011902
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number227200
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number32742
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: