=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144211582
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TULSA X-RAY LABORATORY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 S UTICA AVE
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74104-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-934-8347
-----------------------------------------------------
Fax | 918-917-4114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5801 E 41ST ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74135-5618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-934-8347
-----------------------------------------------------
Fax | 918-743-8552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JASON MARTENS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 918-934-8347
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------