Provider Demographics
NPI:1255671806
Name:ADA PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:ADA PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:WEESNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-332-7337
Mailing Address - Street 1:1414 ARLINGTON ST
Mailing Address - Street 2:SUITE 1700
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2646
Mailing Address - Country:US
Mailing Address - Phone:580-332-7337
Mailing Address - Fax:580-332-3881
Practice Address - Street 1:1414 ARLINGTON ST
Practice Address - Street 2:SUITE 1700
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2646
Practice Address - Country:US
Practice Address - Phone:580-332-7337
Practice Address - Fax:580-332-3881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16267208000000X
OK0065815363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100130860BMedicaid
OK200055950AMedicaid
OK200055950AMedicaid