Provider Demographics
NPI:1013421023
Name:SUSAN C. WILLARD, DO, PLLC
Entity Type:Organization
Organization Name:SUSAN C. WILLARD, DO, PLLC
Other - Org Name:FAMILY HEALTH AND WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-740-4630
Mailing Address - Street 1:6532 E. 71ST STREET
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133
Mailing Address - Country:US
Mailing Address - Phone:918-740-4630
Mailing Address - Fax:918-289-0091
Practice Address - Street 1:6532 E. 71ST STREET
Practice Address - Street 2:SUITE 150
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133
Practice Address - Country:US
Practice Address - Phone:918-740-4630
Practice Address - Fax:918-289-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty