Basic Information
Provider Information | |||||||||
NPI: | 1457392409 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROELOFS | ||||||||
FirstName: | CARYN | ||||||||
MiddleName: | JEAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2345 SOUTHWEST BLVD | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741072705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185611131 | ||||||||
FaxNumber: | 9185859273 | ||||||||
Practice Location | |||||||||
Address1: | 2345 SOUTHWEST BLVD | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741072705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185611131 | ||||||||
FaxNumber: | 9185859273 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2006 | ||||||||
LastUpdateDate: | 07/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | 4361 | OK | Y |   | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |   |
ID Information
ID | Type | State | Issuer | Description | 200078640A | 05 | OK |   | MEDICAID |