Provider Demographics
NPI:1649565821
Name:KEPHART, JOHN H (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:KEPHART
Suffix:
Gender:M
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:PO BOX 54760
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74155-4760
Mailing Address - Country:US
Mailing Address - Phone:918-392-1705
Mailing Address - Fax:
Practice Address - Street 1:940 NE 13TH ST
Practice Address - Street 2:SUITE 4G 4200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5008
Practice Address - Country:US
Practice Address - Phone:405-271-8001
Practice Address - Fax:405-271-3375
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014362207Q00000X
OK57612085R0202X
OK390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARES0000Medicare UPIN