Provider Demographics
NPI:1245392505
Name:RENTERIA-LUCIUS, GAMAL H (RPT)
Entity Type:Individual
Prefix:MRS
First Name:GAMAL
Middle Name:H
Last Name:RENTERIA-LUCIUS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MRS
Other - First Name:GAMAL
Other - Middle Name:H
Other - Last Name:LUCIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:2318 S 109TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-5030
Mailing Address - Country:US
Mailing Address - Phone:918-851-5072
Mailing Address - Fax:918-619-6077
Practice Address - Street 1:5950 E 31ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5114
Practice Address - Country:US
Practice Address - Phone:918-851-5072
Practice Address - Fax:918-619-6077
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK242408600Medicare ID - Type Unspecified