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General NPI Number Information
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NPI Number | 1528230638
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Entity Type | Organization
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Legal Business Name | GEORGE BOVASSO
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Dates
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Enumeration Date | 03/28/2008
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Last Update Date | 03/28/2008
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Provider Practice Location Address
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Address Line | 1212 E 58TH ST
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City | TULSA
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State | OK
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Zip | 74105-8401
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Country | US
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Telephone | 918-743-1402
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6395
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City | TULSA
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State | OK
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Zip | 74148-0395
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Country | US
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Telephone | 918-586-3948
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | GEORGE BOVASSO
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Credential | D.O.
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Telephone | 918-586-3948
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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 | 1582
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License Number State | OK
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