Basic Information
| Provider Information | |||||||||
| NPI: | 1225020282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GASBARRA | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | BREWER | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 W MEMORIAL RD | ||||||||
| Address2: | STE 405 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731209350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052925500 | ||||||||
| FaxNumber: | 4052925505 | ||||||||
| Practice Location | |||||||||
| Address1: | 4200 W MEMORIAL RD | ||||||||
| Address2: | STE 405 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731209350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052925500 | ||||||||
| FaxNumber: | 4052925505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 11/08/2012 | ||||||||
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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 | 207RP1001X | 13952 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 10002019OA | 05 | OK | MEDICAID | P00149574 | 01 | OK | RAILROAD MEDICARE | OTHER |