Provider Demographics
NPI:1336128313
Name:INNOVATIVE ORTHOTICS AND PROSTHETICS
Entity Type:Organization
Organization Name:INNOVATIVE ORTHOTICS AND PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOTIST/ PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BREST
Authorized Official - Suffix:
Authorized Official - Credentials:CO CPED
Authorized Official - Phone:918-745-2260
Mailing Address - Street 1:6218 S LEWIS AVE
Mailing Address - Street 2:STE 125
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-1018
Mailing Address - Country:US
Mailing Address - Phone:918-745-2260
Mailing Address - Fax:918-745-2271
Practice Address - Street 1:6218 S LEWIS AVE
Practice Address - Street 2:STE 125
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1018
Practice Address - Country:US
Practice Address - Phone:918-745-2260
Practice Address - Fax:918-745-2271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========0001OtherBCBS
OK=========0001OtherBCBS