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General NPI Number Information
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NPI Number | 1528254109
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Entity Type | Organization
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Legal Business Name | SOUTHERN OKLAHOMA UROLOGY, INC
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Dates
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Enumeration Date | 09/18/2007
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Last Update Date | 09/18/2007
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Provider Practice Location Address
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Address Line | 1414 ARLINGTON ST SUITE 2300
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City | ADA
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State | OK
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Zip | 74820-2643
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Country | US
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Telephone | 580-332-0112
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Fax | 580-332-1005
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Provider Business Mailing Address
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Address Line | 1414 ARLINGTON ST SUITE 2300
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City | ADA
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State | OK
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Zip | 74820-2643
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Country | US
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Telephone | 580-332-0112
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Fax | 580-332-1005
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GLEN E DIACON JR.
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Credential | MD
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Telephone | 580-332-0112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State | OK
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