Provider Demographics
NPI:1316994551
Name:AL-BOTROS, ADONIS S (MD)
Entity type:Individual
Prefix:
First Name:ADONIS
Middle Name:S
Last Name:AL-BOTROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N LEE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-2620
Mailing Address - Country:US
Mailing Address - Phone:405-600-6730
Mailing Address - Fax:405-600-6750
Practice Address - Street 1:1111 N LEE AVE STE 105
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2620
Practice Address - Country:US
Practice Address - Phone:405-600-6730
Practice Address - Fax:405-600-6750
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK217512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100224280AMedicaid
OK100224280AMedicaid