Provider Demographics
NPI:1225062516
Name:HEBERTSON, CHRISTOPHER FIFE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:FIFE
Last Name:HEBERTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12455 E 100TH ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4674
Mailing Address - Country:US
Mailing Address - Phone:918-274-9700
Mailing Address - Fax:918-274-1395
Practice Address - Street 1:12455 E 100TH ST N STE 300
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4674
Practice Address - Country:US
Practice Address - Phone:918-274-9700
Practice Address - Fax:918-274-1395
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41127208000000X
IL036.119839208000000X
OK23479208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNI61397Medicare UPIN