Provider Demographics
NPI:1487647343
Name:KNIPPERS, JOHN CARROLL (MDM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CARROLL
Last Name:KNIPPERS
Suffix:
Gender:M
Credentials:MDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7512 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-6050
Mailing Address - Country:US
Mailing Address - Phone:918-728-2000
Mailing Address - Fax:918-728-2001
Practice Address - Street 1:7512 E 91ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6050
Practice Address - Country:US
Practice Address - Phone:918-728-2000
Practice Address - Fax:918-728-2001
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13860208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE62330Medicare UPIN