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NPI Code Detail

MEDICARE: GEORGE JOSEPH BOVASSO JR. D.O.

MEDICARE: GEORGE JOSEPH BOVASSO JR. D.O.
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
1208000000XPediatrics Physician1582OK

General Provider Information

NPI Number : 1184732570
Entity Type Code : Individual
Provider Name (Legal Business Name) : GEORGE JOSEPH BOVASSO JR. D.O.
Provider Business Mailing Address
First Line : 7659 S QUEBEC AVE
Second Line :
City : TULSA
State : OK
Zip : 74136-8102
Country : US
Telephone Number : 918-428-2538
Fax Number :
Provider Business Practice Location Address
First Line : 940 E 36TH ST N
Second Line :
City : TULSA
State : OK
Zip : 74106-1953
Country : US
Telephone Number : 918-428-2538
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/27/2006
Last Update Date : 11/21/2014

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