Provider Demographics
NPI:1235399122
Name:SOUTH POINTE PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:SOUTH POINTE PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-254-6822
Mailing Address - Street 1:1615 S EUCALYPTUS AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-6159
Mailing Address - Country:US
Mailing Address - Phone:918-254-6822
Mailing Address - Fax:918-254-6823
Practice Address - Street 1:1615 S EUCALYPTUS AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-6159
Practice Address - Country:US
Practice Address - Phone:918-254-6822
Practice Address - Fax:918-254-6823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK238242080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty