Provider Demographics
NPI:1669506507
Name:LESA J BETHEL MULLIGAN MD PC
Entity Type:Organization
Organization Name:LESA J BETHEL MULLIGAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:VINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-928-2972
Mailing Address - Street 1:809 N FINDLAY AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6438
Mailing Address - Country:US
Mailing Address - Phone:405-364-0643
Mailing Address - Fax:405-364-0502
Practice Address - Street 1:809 N FINDLAY
Practice Address - Street 2:STE 100
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071
Practice Address - Country:US
Practice Address - Phone:405-364-0643
Practice Address - Fax:405-364-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18183174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG31862Medicare UPIN