Provider Demographics
NPI:1750489829
Name:BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA
Entity Type:Organization
Organization Name:BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA
Other - Org Name:OU ORAL PATHOLOGY LABORATORY
Other - Org Type:Other Name
Authorized Official - Title/Position:ORAL PATHOLOGY DIVISION HEAD
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:FARAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-271-4333
Mailing Address - Street 1:PO BOX 26901
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-0901
Mailing Address - Country:US
Mailing Address - Phone:405-271-4333
Mailing Address - Fax:405-271-3385
Practice Address - Street 1:1201 N STONEWALL AVE
Practice Address - Street 2:#593
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1214
Practice Address - Country:US
Practice Address - Phone:405-271-4333
Practice Address - Fax:405-271-3385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200006220AMedicaid
OK37D0856444OtherCLIA CERTIFICATE