Provider Demographics
NPI:1114334885
Name:PARK PLACE MEDICAL
Entity Type:Organization
Organization Name:PARK PLACE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:RAYE
Authorized Official - Last Name:COSBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-376-5439
Mailing Address - Street 1:500 PARK PL
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-3104
Mailing Address - Country:US
Mailing Address - Phone:406-376-5439
Mailing Address - Fax:405-376-6459
Practice Address - Street 1:500 PARK PL
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-3104
Practice Address - Country:US
Practice Address - Phone:406-376-5439
Practice Address - Fax:405-376-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15742208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty