Provider Demographics
NPI:1255395984
Name:BETHEL MULLIGAN, LESA JEAN (MD)
Entity type:Individual
Prefix:
First Name:LESA
Middle Name:JEAN
Last Name:BETHEL MULLIGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LESA
Other - Middle Name:JEAN
Other - Last Name:BETHEL MULLIGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1139 36TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4103
Mailing Address - Country:US
Mailing Address - Phone:405-364-0643
Mailing Address - Fax:405-364-0502
Practice Address - Street 1:1139 36TH AVE NW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4103
Practice Address - Country:US
Practice Address - Phone:405-364-0643
Practice Address - Fax:405-364-0502
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18183207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100131240BOtherSOONERCARE
OK100131240AMedicaid