Provider Demographics
NPI:1346746088
Name:SCOZZAFAVA, KYLE M (DO)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:M
Last Name:SCOZZAFAVA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 NW 188TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-5810
Mailing Address - Country:US
Mailing Address - Phone:858-248-7699
Mailing Address - Fax:
Practice Address - Street 1:4401 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109
Practice Address - Country:US
Practice Address - Phone:405-636-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6754207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine