=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902804248
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER ROSS TIPSWORD D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2005
-----------------------------------------------------
Last Update Date | 10/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 SW 160TH AVE SUITE 250
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33027-6308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-399-4621
-----------------------------------------------------
Fax | 877-892-9770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2514 NORTH MERIDIAN AVENUE
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73107-1035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-722-1110
-----------------------------------------------------
Fax | 405-721-8263
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 3988
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------