MEDICARE: DEREK RAY COHLMIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6933	OK

General Provider Information

NPI Number	:	1184154023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK RAY COHLMIA

Provider Business Mailing Address
First Line	:	4301 NW 63RD ST STE 303
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-1504
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4301 NW 63RD ST STE 303
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-1504
Country	:	US
Telephone Number	:	405-848-2886
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2017
Last Update Date	:	06/14/2017

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Directions to “ DEREK RAY COHLMIA ” Practice Location

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