Provider Demographics
NPI:1942335773
Name:DERMATOLOGY AND LASER CENTER OF OKLAHOMA
Entity Type:Organization
Organization Name:DERMATOLOGY AND LASER CENTER OF OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-494-0400
Mailing Address - Street 1:9306 S TOLEDO CT
Mailing Address - Street 2:SUITE #100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-2746
Mailing Address - Country:US
Mailing Address - Phone:918-494-0400
Mailing Address - Fax:918-494-0405
Practice Address - Street 1:9306 S TOLEDO CT
Practice Address - Street 2:SUITE #100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-2746
Practice Address - Country:US
Practice Address - Phone:918-494-0400
Practice Address - Fax:918-494-0405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23102207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK800522239Medicare ID - Type Unspecified
OKH08397Medicare UPIN