Healthcare Provider Details

I. General information

NPI: 1033645361
Provider Name (Legal Business Name): COLBY DEGIACOMO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 E 41ST ST STE 900
TULSA OK
74135-5631
US

IV. Provider business mailing address

5801 E 41ST ST STE 900
TULSA OK
74135-5631
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-8943
  • Fax: 918-743-8552
Mailing address:
  • Phone: 918-743-8943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number6641
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: