Provider Demographics
NPI:1932477965
Name:HEART AND VASCULAR CENTER PLLC
Entity Type:Organization
Organization Name:HEART AND VASCULAR CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:WOODSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-250-4278
Mailing Address - Street 1:3106 NW ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3106 NW ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6123
Practice Address - Country:US
Practice Address - Phone:580-250-4278
Practice Address - Fax:580-581-1548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200069590AMedicaid
800522483Medicare PIN