Provider Demographics
NPI:1376516757
Name:DALTON, KATIE BETH (DO)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:BETH
Last Name:DALTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6528 E 101ST ST
Mailing Address - Street 2:PMB 431 SUITE D1
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-6724
Mailing Address - Country:US
Mailing Address - Phone:918-895-7808
Mailing Address - Fax:918-895-7807
Practice Address - Street 1:7723 E 91ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6053
Practice Address - Country:US
Practice Address - Phone:918-895-7808
Practice Address - Fax:918-895-7807
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4061208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200020710CMedicaid
OK200020710CMedicaid