Provider Demographics
NPI:1932118304
Name:LEVERIDGE, CHARLES TONY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:TONY
Last Name:LEVERIDGE
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 1:4140 W MEMORIAL #413
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120
Mailing Address - Country:US
Mailing Address - Phone:405-755-2230
Mailing Address - Fax:405-755-0389
Practice Address - Street 1:4140 W MEMORIAL #413
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120
Practice Address - Country:US
Practice Address - Phone:405-755-2230
Practice Address - Fax:405-755-0389
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13166208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics