Provider Demographics
NPI:1508978149
Name:SOUTHERN OKLAHOMA PATHOLOGY ASSOC., INC.
Entity Type:Organization
Organization Name:SOUTHERN OKLAHOMA PATHOLOGY ASSOC., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:MOORING
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:800-288-8325
Mailing Address - Street 1:421 N MONTE VISTA ST
Mailing Address - Street 2:PATHOLOGY DEPARTMENT
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4609
Mailing Address - Country:US
Mailing Address - Phone:580-332-9595
Mailing Address - Fax:580-332-4921
Practice Address - Street 1:421 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4609
Practice Address - Country:US
Practice Address - Phone:580-332-9595
Practice Address - Fax:580-332-4921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8286207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKCO5064OtherRAILROAD MEDICARE
OK100758421BMedicaid
OKCO5064OtherRAILROAD MEDICARE