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General NPI Number Information
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NPI Number | 1972796274
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Entity Type | Organization
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Legal Business Name | ADVANCED UROLOGY AND WELLNESS CENTER OF MUSKOGEE PLLC
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Dates
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Enumeration Date | 08/21/2007
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Last Update Date | 04/16/2013
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Provider Practice Location Address
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Address Line | 4200 W OKMULGEE ST
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City | MUSKOGEE
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State | OK
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Zip | 74401-4646
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Country | US
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Telephone | 918-683-5025
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Fax | 918-913-9703
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Provider Business Mailing Address
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Address Line | 4200 W OKMULGEE ST
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City | MUSKOGEE
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State | OK
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Zip | 74401-4646
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Country | US
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Telephone | 918-683-5025
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Fax | 918-913-9703
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. JEWELL LEE DANIELS JR.
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Credential | MD
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Telephone | 918-683-5025
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 23095
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License Number State | OK
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