MEDICARE: ETHAN LEE ALLISON MD

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	207P00000X	Emergency Medicine Physician	41687	OK
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1386263606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHAN LEE ALLISON MD

Provider Business Mailing Address
First Line	:	1111 S SAINT LOUIS AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74120-5440
Country	:	US
Telephone Number	:	918-619-4751
Fax Number	:

Provider Business Practice Location Address
First Line	:	5441 S LOUISVILLE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-3815
Country	:	US
Telephone Number	:	931-217-0984
Fax Number	:

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

Provider Enumeration Date	:	04/16/2020
Last Update Date	:	03/16/2026

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