Basic Information
Provider Information | |||||||||
NPI: | 1851318497 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TULSA NEUROLOGY CLINIC INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7134 S YALE AVE | ||||||||
Address2: | SUITE 450 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741366372 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187432882 | ||||||||
FaxNumber: | 9187450323 | ||||||||
Practice Location | |||||||||
Address1: | 7134 S YALE AVE | ||||||||
Address2: | SUITE 450 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741366372 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187432882 | ||||||||
FaxNumber: | 9187450323 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2006 | ||||||||
LastUpdateDate: | 09/28/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHNSON | ||||||||
AuthorizedOfficialFirstName: | JAY | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9187432882 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 100137280A | 05 | OK |   | MEDICAID | 1851318497 | 01 | OK | NPI | OTHER | 448664025001 | 01 |   | BCBS | OTHER | DP2445 | 01 | OK | RAILROAD MEDICARE | OTHER |