Provider Demographics
NPI:1003094665
Name:KEBERT, CORY BRIT (MD)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:BRIT
Last Name:KEBERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 E BRYAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4513
Mailing Address - Country:US
Mailing Address - Phone:918-748-7557
Mailing Address - Fax:
Practice Address - Street 1:1717 S UTICA AVE STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5346
Practice Address - Country:US
Practice Address - Phone:981-748-7557
Practice Address - Fax:918-748-7514
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26794207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK403381Medicare PIN
OKOK403380Medicare PIN