Basic Information
| Provider Information | |||||||||
| NPI: | 1679533939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAW | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 N MIDWEST BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731104321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056102100 | ||||||||
| FaxNumber: | 4056102101 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 N MIDWEST BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731104321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056102100 | ||||||||
| FaxNumber: | 4056102101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 23822 | OK | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 200028150A | 05 | OK | MEDICAID |