Basic Information
| Provider Information | |||||||||
| NPI: | 1972770386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PREVO | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | TIMOTHY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 NW 9TH ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052312900 | ||||||||
| FaxNumber: | 4052724905 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 NW 9TH ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052312900 | ||||||||
| FaxNumber: | 4052724905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M8261 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 208VP0014X | 29457 | OK | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.