MEDICARE: DERMATOLOGY ASSOCIATES OF OKLAHOMA LLC

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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1316331986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY ASSOCIATES OF OKLAHOMA LLC

Provider Business Mailing Address
First Line	:	6966 S UTICA AVE
Second Line	:	STE. 225
City	:	TULSA
State	:	OK
Zip	:	74136-3903
Country	:	US
Telephone Number	:	918-492-6333
Fax Number	:

Provider Business Practice Location Address
First Line	:	3130 SW 89TH ST
Second Line	:	STE. 100
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-7908
Country	:	US
Telephone Number	:	405-703-2060
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	ROBERT NEVIN
Credential	:
Telephone Number	:	918-492-6333

Provider Enumeration Date	:	03/23/2015
Last Update Date	:	03/24/2015

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