Provider Demographics
NPI:1225332448
Name:SPOOR-BAKER, MALLORY C (DO)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:C
Last Name:SPOOR-BAKER
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 1:3958 S HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3958 S HUDSON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5608
Practice Address - Country:US
Practice Address - Phone:918-280-0270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3175207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKF84246Medicare UPIN