Provider Demographics
NPI:1386263606
Name:ALLISON, ETHAN LEE (MD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:LEE
Last Name:ALLISON
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 1:4502 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2536
Mailing Address - Country:US
Mailing Address - Phone:918-579-2367
Mailing Address - Fax:
Practice Address - Street 1:5441 S LOUISVILLE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3815
Practice Address - Country:US
Practice Address - Phone:931-217-0984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program