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General NPI Number Information
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NPI Number | 1295840155
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Entity Type | Organization
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Legal Business Name | BREAST SURGERY OF TULSA P L L C
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Dates
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Enumeration Date | 08/20/2006
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Last Update Date | 07/23/2007
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Provider Practice Location Address
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Address Line | 1120 S UTICA AVE STE G200
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City | TULSA
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State | OK
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Zip | 74104-4012
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Country | US
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Telephone | 918-299-8232
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 21228 DEPT 229
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City | TULSA
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State | OK
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Zip | 74121-1228
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Country | US
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Telephone | 918-299-8232
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LANETTE F SMITH
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Credential | MD
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Telephone | 918-299-8232
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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