Provider Demographics
NPI:1386880698
Name:REEVES, RENETTA (MD)
Entity type:Individual
Prefix:
First Name:RENETTA
Middle Name:
Last Name:REEVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RENETTA
Other - Middle Name:
Other - Last Name:BULLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4500 S 129TH EAST AVE
Mailing Address - Street 2:SUITE 191
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-5801
Mailing Address - Country:US
Mailing Address - Phone:800-993-8244
Mailing Address - Fax:
Practice Address - Street 1:4500 S 129TH EAST AVE
Practice Address - Street 2:SUITE 191
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74134-5801
Practice Address - Country:US
Practice Address - Phone:800-993-8244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 62145207QA0505X
OK16980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17769ZOtherMEDICARE PTAN