Provider Demographics
NPI:1528037926
Name:MERTZ, CORNELIA O (DO)
Entity Type:Individual
Prefix:
First Name:CORNELIA
Middle Name:O
Last Name:MERTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-2705
Mailing Address - Country:US
Mailing Address - Phone:918-561-5701
Mailing Address - Fax:
Practice Address - Street 1:2345 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-2705
Practice Address - Country:US
Practice Address - Phone:918-582-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100248070BMedicaid
OK100248070BMedicaid
OKE09763Medicare ID - Type Unspecified
249300803Medicare PIN