Provider Demographics
NPI:1528230638
Name:GEORGE BOVASSO
Entity Type:Organization
Organization Name:GEORGE BOVASSO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOVASSO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-586-3948
Mailing Address - Street 1:PO BOX 6395
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74148-0395
Mailing Address - Country:US
Mailing Address - Phone:918-586-3948
Mailing Address - Fax:
Practice Address - Street 1:1212 E 58TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-8401
Practice Address - Country:US
Practice Address - Phone:918-743-1402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1582208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty