Provider Demographics
NPI:1619363835
Name:ETHERIDGE, WILLIAM ROBERT (BOC LP)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ROBERT
Last Name:ETHERIDGE
Suffix:
Gender:M
Credentials:BOC LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 WESTPARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-4032
Mailing Address - Country:US
Mailing Address - Phone:405-701-3733
Mailing Address - Fax:405-701-3752
Practice Address - Street 1:2202 WESTPARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-4032
Practice Address - Country:US
Practice Address - Phone:405-701-3733
Practice Address - Fax:405-701-3752
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKC21410224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist