Basic Information
| Provider Information | |||||||||
| NPI: | 1508172982 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TULSA CANCER INSTITUTE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12697 E 51ST ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741466236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185053200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12697 E 51ST ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741466236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185053200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2010 | ||||||||
| LastUpdateDate: | 05/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | STREET | ||||||||
| AuthorizedOfficialFirstName: | DARON | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9185053200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 2085R0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 200412430A | 05 | OK | MEDICAID |