Provider Demographics
NPI:1194741561
Name:TULSA DERMATOLOGY CLINIC INC
Entity type:Organization
Organization Name:TULSA DERMATOLOGY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-749-2261
Mailing Address - Street 1:PO BOX 52588
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74152-0588
Mailing Address - Country:US
Mailing Address - Phone:918-749-2261
Mailing Address - Fax:918-749-8712
Practice Address - Street 1:2121 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-1409
Practice Address - Country:US
Practice Address - Phone:918-749-2261
Practice Address - Fax:918-749-8712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100729380AMedicaid
OK=========001OtherBLUE CROSS BLUE SHIELD
OK=========Medicare ID - Type Unspecified