Basic Information
| Provider Information | |||||||||
| NPI: | 1578853651 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 S HOUSTON AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183824600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 717 S HOUSTON AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183824600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 5185 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200440820B | 05 | OK | MEDICAID |