Provider Demographics
NPI:1124118773
Name:OKLAHOMA OTOLARYNGOLOGY ASSOCIATES, LLC
Entity type:Organization
Organization Name:OKLAHOMA OTOLARYNGOLOGY ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-755-6651
Mailing Address - Street 1:P.O. BOX 96-0119
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0119
Mailing Address - Country:US
Mailing Address - Phone:405-755-6651
Mailing Address - Fax:405-755-2795
Practice Address - Street 1:3033 NW 63RD STREET
Practice Address - Street 2:152E
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-3634
Practice Address - Country:US
Practice Address - Phone:405-755-6651
Practice Address - Fax:405-755-2795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK800522207Medicare UPIN