Provider Demographics
NPI:1457796039
Name:PEDIATRIC SPECIALISTS OF TULSA
Entity type:Organization
Organization Name:PEDIATRIC SPECIALISTS OF TULSA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:M
Authorized Official - Last Name:O'SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-523-5437
Mailing Address - Street 1:7412 S YALE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7029
Mailing Address - Country:US
Mailing Address - Phone:918-523-5437
Mailing Address - Fax:918-523-5438
Practice Address - Street 1:7412 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7029
Practice Address - Country:US
Practice Address - Phone:918-523-5437
Practice Address - Fax:918-523-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21759208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty