=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881826923
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PITTMAN FOOT SPECIALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2009
-----------------------------------------------------
Last Update Date | 10/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 CHANDLER RD SUITE 109
-----------------------------------------------------
City | MUSKOGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74403-4957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-682-3668
-----------------------------------------------------
Fax | 918-682-4127
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 CHANDLER RD SUITE 109
-----------------------------------------------------
City | MUSKOGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74403-4957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-682-3668
-----------------------------------------------------
Fax | 918-682-4127
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LARRY HALE PITTMAN JR.
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 918-682-3668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 257
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------