Basic Information
| Provider Information | |||||||||
| NPI: | 1891859856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULL | ||||||||
| FirstName: | MINDI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W BOISE CIR | ||||||||
| Address2: | STE 150 | ||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740124906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189949150 | ||||||||
| FaxNumber: | 9184036323 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 W BOISE CIR | ||||||||
| Address2: | STE 150 | ||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740124906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189949150 | ||||||||
| FaxNumber: | 9184036323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 10/17/2018 | ||||||||
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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 | 207Y00000X | 4384 | OK | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 200101160A | 05 | OK | MEDICAID |