Basic Information
| Provider Information | |||||||||
| NPI: | 1427577923 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OKLAHOMA WESLEYAN UNIVERSITY | ||||||||
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| OtherOrganizationName: | OKWU SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SPRING VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752443995 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2201 SILVER LAKE RD | ||||||||
| Address2: | |||||||||
| City: | BARTLESVILLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740066233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723674845 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2017 | ||||||||
| LastUpdateDate: | 09/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | BASS | ||||||||
| AuthorizedOfficialFirstName: | MOUZON | ||||||||
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| AuthorizedOfficialTitleorPosition: | AGENT | ||||||||
| AuthorizedOfficialTelephone: | 9723674845 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3219 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.