Provider Demographics
NPI:1639479348
Name:MILESTONE PEDIATRIC CARE, PLLC
Entity Type:Organization
Organization Name:MILESTONE PEDIATRIC CARE, PLLC
Other - Org Name:MILESTONES PEDIATRIC CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:HENLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-745-0800
Mailing Address - Street 1:3845 S 103RD EAST AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-2452
Mailing Address - Country:US
Mailing Address - Phone:918-745-0800
Mailing Address - Fax:918-745-0028
Practice Address - Street 1:3863 S 103RD EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-2443
Practice Address - Country:US
Practice Address - Phone:918-745-0800
Practice Address - Fax:918-745-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4195208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200312980AMedicaid