Basic Information
| Provider Information | |||||||||
| NPI: | 1083609861 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREIPOHL | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 1654 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741820001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059478585 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Practice Location | |||||||||
| Address1: | 9423 E 95TH CT | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741335805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184962400 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
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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 | 207L00000X | 16657 | OK | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 54361 | AZ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 4854514 | 01 | OK | CIGNA | OTHER | 050072987 | 01 | OK | RAILROAD MEDICARE | OTHER | 100194990C | 05 | OK | MEDICAID |