Healthcare Provider Details

I. General information

NPI: 1538797428
Provider Name (Legal Business Name): BRANDON KITCHENS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 04/17/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4812 S 109TH EAST AVE
TULSA OK
74146-5826
US

IV. Provider business mailing address

4812 S 109TH EAST AVE
TULSA OK
74146-5826
US

V. Phone/Fax

Practice location:
  • Phone: 918-236-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number59.000978
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number399
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: