Healthcare Provider Details

I. General information

NPI: 1427143429
Provider Name (Legal Business Name): RICARDO MARIANO VALBUENA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 WEST MAIN STREET
WILBURTON OK
74578
US

IV. Provider business mailing address

1107 WEST MAIN STREET
WILBURTON OK
74578
US

V. Phone/Fax

Practice location:
  • Phone: 918-465-5681
  • Fax: 918-465-5682
Mailing address:
  • Phone: 918-465-5681
  • Fax: 918-465-5682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12464
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: