Healthcare Provider Details

I. General information

NPI: 1790121499
Provider Name (Legal Business Name): LISA MASK BULL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9245 S MINGO RD
TULSA OK
74133
US

IV. Provider business mailing address

9245 S MINGO RD
TULSA OK
74133-5793
US

V. Phone/Fax

Practice location:
  • Phone: 918-492-8980
  • Fax: 918-495-0607
Mailing address:
  • Phone: 918-492-8980
  • Fax: 918-495-0607

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 Code207N00000X
TaxonomyDermatology Physician
License Number30038
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: