Provider Demographics
NPI:1720204761
Name:AVALON PARK PEDIATRICS
Entity Type:Organization
Organization Name:AVALON PARK PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:RALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-398-7170
Mailing Address - Street 1:7779 EAST 106TH STREET
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-6844
Mailing Address - Country:US
Mailing Address - Phone:918-398-7170
Mailing Address - Fax:918-398-7199
Practice Address - Street 1:6528 E 101ST ST
Practice Address - Street 2:SUITE D-1, PMB 419
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6724
Practice Address - Country:US
Practice Address - Phone:918-398-7170
Practice Address - Fax:918-398-7199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20582208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty