Provider Demographics
NPI:1205815537
Name:LAKIN-SOUTHERN, KAYLA (DO)
Entity Type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:
Last Name:LAKIN-SOUTHERN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 S REDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-1473
Mailing Address - Country:US
Mailing Address - Phone:918-521-3688
Mailing Address - Fax:
Practice Address - Street 1:10109 E 79TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4564
Practice Address - Country:US
Practice Address - Phone:918-521-3688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2306207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK930108407OtherMEDICARE RAILROAD
OK100227370AMedicaid
OK$$$$$$$$$007OtherBLUE CROSS-EMERGENCY MANAGEMENT ASSOCIATES PC
OK$$$$$$$$$-009OtherBLUE CROSS-URGENT CARE OF GREEN COUNTRY-OWASSO
OK$$$$$$$$$-008OtherBLUE CROSS-URGENT CARE OF GREEN COUNTRY-BIXBY
OK930108407OtherMEDICARE RAILROAD
OK100227370AMedicaid
OK$$$$$$$$$-010OtherBLUE CROSS-URGENT CARE OF GREEN COUNTRY-CLAREMORE
OK$$$$$$$$$XMedicare PIN