Provider Demographics
NPI:1437130069
Name:OKLAHOMA CARDIOVASCULAR ASSOCIATES. PC
Entity Type:Organization
Organization Name:OKLAHOMA CARDIOVASCULAR ASSOCIATES. PC
Other - Org Name:OKLAHOMA CARDIOVASCULAR ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:KLAKULAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-608-3800
Mailing Address - Street 1:4050 W MEMORIAL RD
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8382
Mailing Address - Country:US
Mailing Address - Phone:405-608-3800
Mailing Address - Fax:405-608-3838
Practice Address - Street 1:4050 W MEMORIAL RD
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8382
Practice Address - Country:US
Practice Address - Phone:405-608-3800
Practice Address - Fax:405-608-3838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
OK207RC0000X, 207RC0001X, 207RI0011X, 207RP1001X, 207UN0901X, 208600000X, 2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746160AMedicaid
OKCD6448OtherRRMDR
OKCD6448OtherRRMDR