Basic Information
| Provider Information | |||||||||
| NPI: | 1104132646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS-JOHNSON | ||||||||
| FirstName: | BRETONYA | ||||||||
| MiddleName: | JANEY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12317 WILLIAMSPORT AVENUE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056251778 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5501 N PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731122074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056046000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2010 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 125058881 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 30415 | OK | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 30415 | 01 | OK | MEDICAL LICENSE | OTHER | 125058881 | 01 | IL | MEDICAL LICENSE | OTHER |