Basic Information
Provider Information | |||||||||
NPI: | 1538483698 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OKLAHOMA ONCOLOGY AND HEMATOLOGY, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CANCER CARE ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4401 W MEMORIAL RD | ||||||||
Address2: | 138 | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731341785 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4059362812 | ||||||||
FaxNumber: | 4059362891 | ||||||||
Practice Location | |||||||||
Address1: | 9320 S MINGO RD | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741335710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184594000 | ||||||||
FaxNumber: | 9184595045 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/18/2010 | ||||||||
LastUpdateDate: | 03/18/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CANFIELD | ||||||||
AuthorizedOfficialFirstName: | VIKKI | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | PAST PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4057514343 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | OKLAHOMA ONCOLOGY AND HEMATOLOGY, P.C. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | 100744480A | 05 | OK |   | MEDICAID |