Provider Demographics
NPI:1467802108
Name:BALTUANO SONGHURST, MIRIAM MELISSA (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:MELISSA
Last Name:BALTUANO SONGHURST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CHILDRENS AVE STE 1F
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4637
Mailing Address - Country:US
Mailing Address - Phone:405-271-4113
Mailing Address - Fax:405-271-2144
Practice Address - Street 1:1200 CHILDRENS AVE STE 1F
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4637
Practice Address - Country:US
Practice Address - Phone:405-271-4113
Practice Address - Fax:405-271-2144
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2022-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1556082084N0402X
IL125.068136208000000X
OK395382084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics