Healthcare Provider Details

I. General information

NPI: 1326484163
Provider Name (Legal Business Name): CHARLES JOHNSON R.P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S GARNETT RD
TULSA OK
74146-5229
US

IV. Provider business mailing address

5739 E 65TH ST
TULSA OK
74136-2721
US

V. Phone/Fax

Practice location:
  • Phone: 918-664-9892
  • Fax:
Mailing address:
  • Phone: 918-513-2493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number13OK1467
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: