Provider Demographics
NPI:1962793018
Name:GASKAMP, MIRANDA CELESTE (DO)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:CELESTE
Last Name:GASKAMP
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 S UTICA AVE
Mailing Address - Street 2:STE A
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5346
Mailing Address - Country:US
Mailing Address - Phone:918-519-8364
Mailing Address - Fax:
Practice Address - Street 1:744 W 9TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9020
Practice Address - Country:US
Practice Address - Phone:918-587-2561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK5213207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program