Basic Information
| Provider Information | |||||||||
| NPI: | 1932142361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HULSEY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 RENAISSANCE BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730133084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058444978 | ||||||||
| FaxNumber: | 0584400562 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 RENAISSANCE BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730133084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058444978 | ||||||||
| FaxNumber: | 4058440562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | L2330 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | 17394 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 147171601 | 05 | TX | MEDICAID |