Provider Demographics
NPI:1932507605
Name:ID CONSULTANTS PLLC
Entity Type:Organization
Organization Name:ID CONSULTANTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-212-9393
Mailing Address - Street 1:8609 WILLOW SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-8250
Mailing Address - Country:US
Mailing Address - Phone:918-361-2825
Mailing Address - Fax:770-573-9513
Practice Address - Street 1:8609 WILLOW SPRINGS CT
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-8250
Practice Address - Country:US
Practice Address - Phone:918-361-2825
Practice Address - Fax:770-573-9513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24139207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200037750AMedicaid
OK24139OtherSTATE LICENSE
OK200037750AMedicaid
OK24139OtherSTATE LICENSE