Provider Demographics
NPI:1215920293
Name:SOUTH TULSA PEDIATRICS PLLJ
Entity type:Organization
Organization Name:SOUTH TULSA PEDIATRICS PLLJ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-728-2888
Mailing Address - Street 1:7512 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-6050
Mailing Address - Country:US
Mailing Address - Phone:918-728-2000
Mailing Address - Fax:917-728-2000
Practice Address - Street 1:7512 E 91ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6050
Practice Address - Country:US
Practice Address - Phone:918-728-2000
Practice Address - Fax:917-728-2000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2732208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE89584Medicare UPIN