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General NPI Number Information
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NPI Number | 1114334885
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Entity Type | Organization
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Legal Business Name | PARK PLACE MEDICAL
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Dates
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Enumeration Date | 07/15/2014
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Last Update Date | 07/15/2014
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Provider Practice Location Address
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Address Line | 500 PARK PL
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City | MUSTANG
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State | OK
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Zip | 73064-3104
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Country | US
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Telephone | 406-376-5439
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Fax | 405-376-6459
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Provider Business Mailing Address
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Address Line | 500 PARK PL
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City | MUSTANG
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State | OK
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Zip | 73064-3104
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Country | US
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Telephone | 406-376-5439
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Fax | 405-376-6459
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Authorized Official
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Title or Position | OWNER
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Name | DR. DONNA RAYE COSBY
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Credential | MD
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Telephone | 405-376-5439
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 15742
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License Number State | OK
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