Provider Demographics
NPI:1326823485
Name:NORTHERN OKLAHOMA DERMATOLOGY
Entity Type:Organization
Organization Name:NORTHERN OKLAHOMA DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:MIETUS
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:405-205-7072
Mailing Address - Street 1:309 SE FRANK PHILLIPS BLVD
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-3643
Mailing Address - Country:US
Mailing Address - Phone:918-214-8888
Mailing Address - Fax:918-214-8887
Practice Address - Street 1:309 SE FRANK PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-3643
Practice Address - Country:US
Practice Address - Phone:918-214-8888
Practice Address - Fax:918-214-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty