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General NPI Number Information
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NPI Number | 1700671492
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Entity Type | Organization
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Legal Business Name | OTTWELL DERMATOLOGY PLLC
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Dates
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Enumeration Date | 04/12/2025
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Last Update Date | 04/12/2025
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Provider Practice Location Address
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Address Line | 3915 E 51ST ST
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City | TULSA
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State | OK
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Zip | 74135-3605
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Country | US
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Telephone | 918-991-8718
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Fax |
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Provider Business Mailing Address
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Address Line | 6224 S 223RD EAST AVE
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City | BROKEN ARROW
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State | OK
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Zip | 74014-2029
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Country | US
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Telephone | 918-991-8718
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. RYAN LUCAS OTTWELL
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Credential | DO
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Telephone | 918-991-8718
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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 |
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