Provider Demographics
NPI:1699295162
Name:FENZL, DERIC (DPT)
Entity type:Individual
Prefix:
First Name:DERIC
Middle Name:
Last Name:FENZL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4812 E 33RD ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2038
Mailing Address - Country:US
Mailing Address - Phone:918-622-4126
Mailing Address - Fax:918-270-2398
Practice Address - Street 1:1486 S ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-8002
Practice Address - Country:US
Practice Address - Phone:918-825-2333
Practice Address - Fax:918-825-6266
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist