Provider Demographics
NPI:1245428689
Name:LUIS V GOROSPE MD PC
Entity Type:Organization
Organization Name:LUIS V GOROSPE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:V
Authorized Official - Last Name:GOROSPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-252-2800
Mailing Address - Street 1:PO BOX 35567
Mailing Address - Street 2:TRIAD BANK
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74153
Mailing Address - Country:US
Mailing Address - Phone:918-252-2800
Mailing Address - Fax:918-252-2888
Practice Address - Street 1:705 W QUEENS ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-1767
Practice Address - Country:US
Practice Address - Phone:918-252-2800
Practice Address - Fax:918-252-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10249208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK110112850BMedicaid