Provider Demographics
NPI:1043335342
Name:MORRISETT, MARK DALLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DALLAS
Last Name:MORRISETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2819 N LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74110-1850
Mailing Address - Country:US
Mailing Address - Phone:918-425-1311
Mailing Address - Fax:918-425-1313
Practice Address - Street 1:2819 N LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74110-1850
Practice Address - Country:US
Practice Address - Phone:918-425-1311
Practice Address - Fax:918-425-1313
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3367111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU64386Medicare UPIN