Provider Demographics
NPI:1528254109
Name:SOUTHERN OKLAHOMA UROLOGY, INC
Entity type:Organization
Organization Name:SOUTHERN OKLAHOMA UROLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:DIACON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:580-332-0112
Mailing Address - Street 1:1414 ARLINGTON ST
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2643
Mailing Address - Country:US
Mailing Address - Phone:580-332-0112
Mailing Address - Fax:580-332-1005
Practice Address - Street 1:1414 ARLINGTON ST
Practice Address - Street 2:SUITE 2300
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2643
Practice Address - Country:US
Practice Address - Phone:580-332-0112
Practice Address - Fax:580-332-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty