Basic Information
| Provider Information | |||||||||
| NPI: | 1760703730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | ALLYSON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 N INDEPENDENCE AVE | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057736470 | ||||||||
| FaxNumber: | 4057736463 | ||||||||
| Practice Location | |||||||||
| Address1: | 5915 W MEMORIAL RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731422021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057736470 | ||||||||
| FaxNumber: | 4057736463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2010 | ||||||||
| LastUpdateDate: | 07/14/2017 | ||||||||
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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 | 27886 | OK | N | Allopathic & Osteopathic Physicians | Pediatrics | 207N00000X | 27886 | OK | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.