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>> Pediatrics >> Allopathic & Osteopathic Physicians

Registrant NPI Number: 1134273444

Individual Registrant:
Gender: M
Sole Proprietor

Location and contact information for practice:
415 FAIRVIEW AVE STE 100  PONCA CITY, OK 74601-1923 US
Tel: 580-765-5569  Fax: 580-765-2020

Contact information for business:
415 FAIRVIEW AVE STE 100  PONCA CITY, OK 74601-1923 US
Tel: 580-765-5569  Fax: 580-765-2020

Registration Information:
NPI: 1134273444
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y208000000XAllopathic & Osteopathic Physicians

Legacy codes, insurance codes and state license numbers:



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