Provider Demographics
NPI:1972512523
Name:SERBOUSEK, LEANN CATHERINE (MD)
Entity Type:Individual
Prefix:DR
First Name:LEANN
Middle Name:CATHERINE
Last Name:SERBOUSEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:4200 W MEMORIAL RD
Practice Address - Street 2:901
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9350
Practice Address - Country:US
Practice Address - Phone:405-749-4247
Practice Address - Fax:405-749-4249
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK15897207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100188650AMedicaid
OK$$$$$$$$$PMedicare PIN
OKE73484Medicare UPIN