Provider Demographics
NPI:1306493754
Name:OKLAHOMA SPECIALTY PODIATRY SERVICES LLC
Entity type:Organization
Organization Name:OKLAHOMA SPECIALTY PODIATRY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-471-6190
Mailing Address - Street 1:PO BOX 8574
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-8574
Mailing Address - Country:US
Mailing Address - Phone:405-471-6190
Mailing Address - Fax:405-285-8921
Practice Address - Street 1:4422 WAGONWHEEL RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5962
Practice Address - Country:US
Practice Address - Phone:405-204-1703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric