Provider Demographics
NPI:1063573459
Name:AL-BOTROS PLLC
Entity type:Organization
Organization Name:AL-BOTROS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ADONIS
Authorized Official - Middle Name:SIMON
Authorized Official - Last Name:AL-BOTROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-600-6730
Mailing Address - Street 1:1111 N LEE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-2620
Mailing Address - Country:US
Mailing Address - Phone:405-600-6730
Mailing Address - Fax:405-600-6750
Practice Address - Street 1:1111 N LEE AVE STE 105
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2620
Practice Address - Country:US
Practice Address - Phone:405-600-6730
Practice Address - Fax:405-600-6750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK217512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100224280AMedicaid
OK100224280AMedicaid
OK248508101Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE