Provider Demographics
NPI:1104803956
Name:INTER ID INC
Entity type:Organization
Organization Name:INTER ID INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DILLIER
Authorized Official - Last Name:ROWLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-494-9486
Mailing Address - Street 1:6565 S YALE AVE
Mailing Address - Street 2:STE 812
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8354
Mailing Address - Country:US
Mailing Address - Phone:918-494-9486
Mailing Address - Fax:918-494-9480
Practice Address - Street 1:6565 S YALE AVE
Practice Address - Street 2:STE 812
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8354
Practice Address - Country:US
Practice Address - Phone:918-494-9486
Practice Address - Fax:918-494-9480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100737010AMedicaid
OK100737010AMedicaid
=========Medicare ID - Type Unspecified