Healthcare Provider Details

I. General information

NPI: 1477553105
Provider Name (Legal Business Name): MARY ELLEN STOCKETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 N COMANCHE AVE
WARR ACRES OK
73132-6646
US

IV. Provider business mailing address

7301 N COMANCHE AVE
WARR ACRES OK
73132-6646
US

V. Phone/Fax

Practice location:
  • Phone: 405-721-8090
  • Fax: 405-722-8529
Mailing address:
  • Phone: 405-721-8090
  • Fax: 405-722-8529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number19659
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: