MEDICARE: OKLAHOMA WEIGHT LOSS SURGERY, PLLC

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	208600000X	Surgery Physician	10249	OK

General Provider Information

NPI Number	:	1720355357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OKLAHOMA WEIGHT LOSS SURGERY, PLLC

Provider Business Mailing Address
First Line	:	8177 S HARVARD AVE # 518
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-1612
Country	:	US
Telephone Number	:	918-252-2800
Fax Number	:	918-252-2888

Provider Business Practice Location Address
First Line	:	705 W QUEENS ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-1767
Country	:	US
Telephone Number	:	918-252-2800
Fax Number	:	918-252-2888

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	LUIS V GOROSPE
Credential	:	MD
Telephone Number	:	918-252-2800

Provider Enumeration Date	:	11/28/2011
Last Update Date	:	12/01/2011

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