Provider Demographics
NPI:1760625032
Name:BASSEY, EDEMEKONG (MD)
Entity Type:Individual
Prefix:
First Name:EDEMEKONG
Middle Name:
Last Name:BASSEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3361
Mailing Address - Country:US
Mailing Address - Phone:918-488-6687
Mailing Address - Fax:918-488-6098
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-502-4254
Practice Address - Fax:918-502-2265
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK33254207RI0200X
MO2013002759207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01272014OtherPALMETTO GBA RAILROAD
MOP01272014OtherPALMETTO GBA RAILROAD
MO502280081Medicare Oscar/Certification