Provider Demographics
NPI:1184732570
Name:BOVASSO, GEORGE JOSEPH JR (DO)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:JOSEPH
Last Name:BOVASSO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7659 S QUEBEC AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8102
Mailing Address - Country:US
Mailing Address - Phone:918-428-2538
Mailing Address - Fax:
Practice Address - Street 1:940 E 36TH ST N
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-1953
Practice Address - Country:US
Practice Address - Phone:918-428-2538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1582208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK238531413Medicare ID - Type Unspecified
OKI45322Medicare UPIN