Provider Demographics
NPI:1003858416
Name:HEFNER WEST MEDICAL CLINIC, P.C.
Entity Type:Organization
Organization Name:HEFNER WEST MEDICAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LABID
Authorized Official - Middle Name:SAM
Authorized Official - Last Name:MUSALLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-942-0090
Mailing Address - Street 1:4400 NW 63RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1545
Mailing Address - Country:US
Mailing Address - Phone:405-942-0090
Mailing Address - Fax:405-942-8055
Practice Address - Street 1:4400 NW 63RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1545
Practice Address - Country:US
Practice Address - Phone:405-942-0090
Practice Address - Fax:405-942-8055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11815173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherEIN
OKE42666Medicare UPIN