MEDICARE: SOUTHERN OKLAHOMA UROLOGY, INC

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	261QM2500X	Medical Specialty Clinic/Center		OK

General Provider Information

NPI Number	:	1528254109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN OKLAHOMA UROLOGY, INC

Provider Business Mailing Address
First Line	:	1414 ARLINGTON ST
Second Line	:	SUITE 2300
City	:	ADA
State	:	OK
Zip	:	74820-2643
Country	:	US
Telephone Number	:	580-332-0112
Fax Number	:	580-332-1005

Provider Business Practice Location Address
First Line	:	1414 ARLINGTON ST
Second Line	:	SUITE 2300
City	:	ADA
State	:	OK
Zip	:	74820-2643
Country	:	US
Telephone Number	:	580-332-0112
Fax Number	:	580-332-1005

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GLEN E DIACON JR.
Credential	:	MD
Telephone Number	:	580-332-0112

Provider Enumeration Date	:	09/18/2007
Last Update Date	:	09/18/2007

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