Healthcare Provider Details

I. General information

NPI: 1376980193
Provider Name (Legal Business Name): KEVIN T QUANG DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 11/29/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5711 E 71ST ST STE 115
TULSA OK
74136-6655
US

IV. Provider business mailing address

701 W. ELGIN ST
BROKEN ARROW OK
74012
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-2955
  • Fax: 918-494-2905
Mailing address:
  • Phone: 918-455-2001
  • Fax: 918-301-0088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number319
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: