Basic Information
| Provider Information | |||||||||
| NPI: | 1336133024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OPONG-KUSI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 S UTICA AVE | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185795749 | ||||||||
| FaxNumber: | 9185795762 | ||||||||
| Practice Location | |||||||||
| Address1: | 1145 S UTICA AVE | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185795749 | ||||||||
| FaxNumber: | 9185795762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | L7833 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 3871 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 3871 | OK | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 100016920A | 05 | OK | MEDICAID | 100016920C | 05 | OK | MEDICAID | 100016920D | 05 | OK | MEDICAID |