Basic Information
| Provider Information | |||||||||
| NPI: | 1760030399 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTIMUM PRIMARY CARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 S BRYANT AVE STE 108 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730346330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053595370 | ||||||||
| FaxNumber: | 4053595481 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 S BRYANT AVE STE 108 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730346330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053595370 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2019 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANAULLAH | ||||||||
| AuthorizedOfficialFirstName: | MUHAMMAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4053595370 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.