Healthcare Provider Details

I. General information

NPI: 1841489333
Provider Name (Legal Business Name): PAIN DIAGNOSIS AND TREATMENT CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8556 E 101ST ST SUITE A
TULSA OK
74133-7033
US

IV. Provider business mailing address

8556 E 101ST ST SUITE A
TULSA OK
74133-7033
US

V. Phone/Fax

Practice location:
  • Phone: 918-369-5511
  • Fax: 918-369-5512
Mailing address:
  • Phone: 918-369-5511
  • Fax: 918-369-5512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BHADRESH BHAKTA
Title or Position: MEMBER
Credential:
Phone: 918-369-5511