=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003014077
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY HALE PITTMAN JR. D.P.M.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2007
-----------------------------------------------------
Last Update Date | 10/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 CHANDLER RD SUITE 105
-----------------------------------------------------
City | MUSKOGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74403-4957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-681-3333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2348
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73083-2348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-616-2386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 257
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------