Provider Demographics
NPI:1225017270
Name:PHILLIPS, LENARD B (DO)
Entity Type:Individual
Prefix:
First Name:LENARD
Middle Name:B
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-5823
Mailing Address - Country:US
Mailing Address - Phone:405-691-5208
Mailing Address - Fax:405-378-0556
Practice Address - Street 1:11601 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-5823
Practice Address - Country:US
Practice Address - Phone:405-691-5208
Practice Address - Fax:405-378-0556
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK247231503Medicare ID - Type Unspecified
OKH31126Medicare UPIN