Basic Information
Provider Information | |||||||||
NPI: | 1558552695 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AL-JIBOORI | ||||||||
FirstName: | AMIRA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4812 E 33RD ST | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741352038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9186224126 | ||||||||
FaxNumber: | 9182702398 | ||||||||
Practice Location | |||||||||
Address1: | 200 N MAIN ST STE C | ||||||||
Address2: |   | ||||||||
City: | SAND SPRINGS | ||||||||
State: | OK | ||||||||
PostalCode: | 740637638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9182450111 | ||||||||
FaxNumber: | 9182453555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2007 | ||||||||
LastUpdateDate: | 06/20/2012 | ||||||||
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 | 225100000X | 3990 | OK | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 200118440 A | 05 | OK |   | MEDICAID | 200118440A | 01 | OK | MEDICAID LEGACY | OTHER | 243725406 | 01 | OK | MEDICARE LEGACY | OTHER | 700522061 | 01 | OK | MEDICARE LEGACY/PROVIDER | OTHER | 7803973 | 01 | OK | AETTNA | OTHER | 731512096001 | 01 | OK | BCBS LEGACY/PROVIDER | OTHER |