Provider Demographics
NPI:1467961524
Name:ALLEN PODIATRY LLC
Entity Type:Organization
Organization Name:ALLEN PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:G
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:II
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-285-8900
Mailing Address - Street 1:PO BOX 8574
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-8574
Mailing Address - Country:US
Mailing Address - Phone:405-285-8900
Mailing Address - Fax:405-285-8921
Practice Address - Street 1:3668 W 70TH PL N
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74126-4384
Practice Address - Country:US
Practice Address - Phone:727-492-2159
Practice Address - Fax:405-285-8921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK255261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200250140AMedicaid