Provider Demographics
NPI:1033194089
Name:FOSTER, BRENT (PT)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:FOSTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 S BRADY ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-5416
Mailing Address - Country:US
Mailing Address - Phone:918-923-4700
Mailing Address - Fax:918-923-4701
Practice Address - Street 1:224 S BRADY ST
Practice Address - Street 2:SUITE 109
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017
Practice Address - Country:US
Practice Address - Phone:918-923-4700
Practice Address - Fax:918-923-4701
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3812225100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200083390AMedicaid
OK200468590AMedicaid