Provider Demographics
NPI:1265459960
Name:HARTSELL, BRENT DEAN (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:DEAN
Last Name:HARTSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4142 S MINGO RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-3632
Mailing Address - Country:US
Mailing Address - Phone:918-744-2553
Mailing Address - Fax:918-744-3482
Practice Address - Street 1:1923 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-6520
Practice Address - Country:US
Practice Address - Phone:918-744-2553
Practice Address - Fax:918-744-3482
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-23927207ZP0102X
TXH4387207ZP0102X
OK18120207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100158850AMedicaid
OK100169690AMedicaid
OK1978Medicaid