Basic Information
| Provider Information | |||||||||
| NPI: | 1447590088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACEFIELD | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | UDEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LACEFIELD | ||||||||
| OtherFirstName: | BEAU | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.0. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 717 S HOUSTON AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183825064 | ||||||||
| FaxNumber: | 9183823589 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 S HOUSTON AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183825064 | ||||||||
| FaxNumber: | 9183823589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2013 | ||||||||
| LastUpdateDate: | 02/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | DO177881 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 5651 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 34.012139 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | OP60641490 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200542440A | 05 | OK | MEDICAID |