Provider Demographics
NPI:1407066228
Name:INNOVATIVE MEDICAL ASSOCIATES PLLC
Entity type:Organization
Organization Name:INNOVATIVE MEDICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:VATSALA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-553-1540
Mailing Address - Street 1:1225 W MAIN ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6824
Mailing Address - Country:US
Mailing Address - Phone:405-292-5500
Mailing Address - Fax:405-292-5505
Practice Address - Street 1:4301 NW 63RD ST
Practice Address - Street 2:SUITE 205
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1549
Practice Address - Country:US
Practice Address - Phone:405-242-6494
Practice Address - Fax:405-242-6496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100748720AMedicaid
OKG46164Medicare UPIN
OK700522018Medicare ID - Type Unspecified
OKD34540Medicare UPIN