Basic Information
| Provider Information | |||||||||
| NPI: | 1477732568 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURGICAL SPECIALISTS OF OKLAHOMA PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BETHANY CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268848 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731268848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058424850 | ||||||||
| FaxNumber: | 4058429612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2349 N THOMPKINS AVE | ||||||||
| Address2: | |||||||||
| City: | BETHANY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730085307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058424850 | ||||||||
| FaxNumber: | 4058429612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2007 | ||||||||
| LastUpdateDate: | 09/19/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4058424850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SURGICAL SPECIALISTS OF OKLAHOMA PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1205879772 | 01 | OK | NPI | OTHER | 1477594513 | 01 | OK | NPI | OTHER |