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General NPI Number Information
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NPI Number | 1730758541
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Entity Type | Organization
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Legal Business Name | LUMINARY DERMATOLOGY OF OKLAHOMA, LLC
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Dates
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Enumeration Date | 06/24/2021
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Last Update Date | 09/24/2021
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Provider Practice Location Address
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Address Line | 1218 E 9TH ST STE 1
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City | EDMOND
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State | OK
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Zip | 73034-5796
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Country | US
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Telephone | 405-856-0020
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Fax | 405-856-0021
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Provider Business Mailing Address
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Address Line | 4411 BEE RIDGE RD PMB 309
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City | SARASOTA
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State | FL
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Zip | 34233-2514
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Country | US
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Telephone | 405-856-0020
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Fax | 405-856-0021
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Authorized Official
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Title or Position | CEO
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Name | MRS. JESSICA PHILLIPS
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Credential |
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Telephone | 941-302-4669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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