Provider Demographics
NPI:1215222583
Name:CENTRAL OKLAHOMA CLINICAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:CENTRAL OKLAHOMA CLINICAL ASSOCIATES, PLLC
Other - Org Name:GEORGE R. PETRY, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-936-0504
Mailing Address - Street 1:9405 NORTH MAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120
Mailing Address - Country:US
Mailing Address - Phone:405-936-0504
Mailing Address - Fax:405-936-0561
Practice Address - Street 1:9405 NORTH MAY AVENUE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120
Practice Address - Country:US
Practice Address - Phone:405-936-0504
Practice Address - Fax:405-936-0561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty