Provider Demographics
NPI:1922296805
Name:SOUTHERN OKLAHOMA INFECTIOUS DISEASES CONSULTANTS, PC
Entity Type:Organization
Organization Name:SOUTHERN OKLAHOMA INFECTIOUS DISEASES CONSULTANTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINONES-NAZARIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-353-1094
Mailing Address - Street 1:PO BOX 6035
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73506-0035
Mailing Address - Country:US
Mailing Address - Phone:580-353-1094
Mailing Address - Fax:580-531-0270
Practice Address - Street 1:5108 W GORE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6025
Practice Address - Country:US
Practice Address - Phone:580-353-1094
Practice Address - Fax:580-531-0270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25783207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
600522412Medicare PIN