Provider Demographics
NPI:1447590088
Name:LACEFIELD, LEONARD UDEL III
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:UDEL
Last Name:LACEFIELD
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BEAU
Other - Middle Name:
Other - Last Name:LACEFIELD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:D0
Mailing Address - Street 1:717 S HOUSTON AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9023
Mailing Address - Country:US
Mailing Address - Phone:918-382-5064
Mailing Address - Fax:918-382-3589
Practice Address - Street 1:717 S HOUSTON AVE STE 310
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9023
Practice Address - Country:US
Practice Address - Phone:918-382-5064
Practice Address - Fax:918-382-3589
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO177881207R00000X
OK5651207R00000X
OH34.012139207R00000X
WAOP60641490207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200542440AMedicaid