Provider Demographics
NPI:1558552695
Name:AL-JIBOORI, AMIRA (MPT)
Entity Type:Individual
Prefix:
First Name:AMIRA
Middle Name:
Last Name:AL-JIBOORI
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4812 E 33RD ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2038
Mailing Address - Country:US
Mailing Address - Phone:918-622-4126
Mailing Address - Fax:918-270-2398
Practice Address - Street 1:200 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-7638
Practice Address - Country:US
Practice Address - Phone:918-245-0111
Practice Address - Fax:918-245-3555
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3990225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200118440 AMedicaid
OK200118440AOtherMEDICAID LEGACY
OK243725406OtherMEDICARE LEGACY
OK700522061OtherMEDICARE LEGACY/PROVIDER
OK7803973OtherAETTNA
OK731512096001OtherBCBS LEGACY/PROVIDER
OK731512096001OtherBCBS LEGACY/PROVIDER