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General NPI Number Information
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NPI Number | 1619363835
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Entity Type | Individual
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Provider Name | WILLIAM ROBERT ETHERIDGE BOC LP
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Gender | Male
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Dates
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Enumeration Date | 04/14/2015
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Last Update Date | 06/23/2015
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Provider Practice Location Address
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Address Line | 2202 WESTPARK DR SUITE A
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City | NORMAN
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State | OK
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Zip | 73069-4032
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Country | US
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Telephone | 405-701-3733
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Fax | 405-701-3752
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Provider Business Mailing Address
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Address Line | 2202 WESTPARK DR SUITE A
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City | NORMAN
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State | OK
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Zip | 73069-4032
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Country | US
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Telephone | 405-701-3733
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Fax | 405-701-3752
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224P00000X
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Taxonomy Name | Prosthetist
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License Number | C21410
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License Number State | OK
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