Basic Information
| Provider Information | |||||||||
| NPI: | 1043287147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULKEY | ||||||||
| FirstName: | LOUIS | ||||||||
| MiddleName: | EDGAR | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1334 N LANSING AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741065907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185872171 | ||||||||
| FaxNumber: | 9182956106 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 S ST LOUIS AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186194600 | ||||||||
| FaxNumber: | 9186194601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3479 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100071920D | 05 | OK | MEDICAID |