Basic Information
| Provider Information | |||||||||
| NPI: | 1871584060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DENNIS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 S GARNETT RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741465238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187286194 | ||||||||
| FaxNumber: | 8559172040 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 S GARNETT RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741465229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187286194 | ||||||||
| FaxNumber: | 9186640267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2452 | OK | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 2452 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100062800A | 05 | OK | MEDICAID |