Healthcare Provider Details

I. General information

NPI: 1164938858
Provider Name (Legal Business Name): PHP YUKON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2017
Last Update Date: 12/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 COMMONS CIR STE B
YUKON OK
73099-9518
US

IV. Provider business mailing address

1820 COMMONS CIR STE B
YUKON OK
73099-9518
US

V. Phone/Fax

Practice location:
  • Phone: 405-265-2778
  • Fax: 405-494-7274
Mailing address:
  • Phone: 405-265-2778
  • Fax: 405-494-7274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21700
License Number StateOK

VIII. Authorized Official

Name: DR. ROBERT LOCKWOOD
Title or Position: OWNER
Credential: MD
Phone: 405-265-2778