=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467992230
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH TULSA ONCOLOGY PROFESSIONALS CANCER ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2017
-----------------------------------------------------
Last Update Date | 01/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13217 S 65TH EAST PL
-----------------------------------------------------
City | BIXBY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74008-3846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-240-9496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13217 S 65TH EAST PL
-----------------------------------------------------
City | BIXBY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74008-3846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-240-9496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/RADIATION ONCOLOGIST
-----------------------------------------------------
Name | DR. WALTER EDWIN WATTS IV
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 918-240-9496
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | 27100
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------