Basic Information
| Provider Information | |||||||||
| NPI: | 1245419340 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURGICAL SPECIALISTS OF OKLAHOMA PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PODIATRY DIVISION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 W WILSHIRE BLVD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731167030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058424850 | ||||||||
| FaxNumber: | 4058429612 | ||||||||
| Practice Location | |||||||||
| Address1: | 3705 NW 63RD ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731161935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052422101 | ||||||||
| FaxNumber: | 4058429612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2007 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4058424850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SURGICAL SPECIALISTS OF OKLAHOMA PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.