Provider Demographics
NPI:1124880570
Name:POWELL, RICHARD MICHAEL
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MICHAEL
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E WACO PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-3813
Mailing Address - Country:US
Mailing Address - Phone:918-625-0412
Mailing Address - Fax:
Practice Address - Street 1:4511 E 55TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-4301
Practice Address - Country:US
Practice Address - Phone:539-525-5883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist