Basic Information
| Provider Information | |||||||||
| NPI: | 1588608293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRATT | ||||||||
| FirstName: | KIMBALL | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1122 NE 13TH ST | ||||||||
| Address2: | ORI 236 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731171039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053255800 | ||||||||
| FaxNumber: | 4057015927 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 24TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053255800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 4301065100 | MI | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 26028 | OK | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3147543-10 | 05 | MI | MEDICAID | 1406100832 | 01 | MI | BLUE CROSS | OTHER | 200194340A | 05 | OK | MEDICAID |