Basic Information
| Provider Information | |||||||||
| NPI: | 1306808316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHERBURN | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268838 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731268838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186194400 | ||||||||
| FaxNumber: | 9186194662 | ||||||||
| Practice Location | |||||||||
| Address1: | 5005 S DARLINGTON AVE # 100 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741357307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186194400 | ||||||||
| FaxNumber: | 9186194662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 01/31/2017 | ||||||||
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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 | 207T00000X | 21448 | OK | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100136580B | 05 | OK | MEDICAID |