Provider Demographics
NPI:1336163724
Name:DERMATOLOGY ASSOCIATES OF TULSA LLC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF TULSA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:YOB
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-307-0215
Mailing Address - Street 1:8803 S 101ST E AVE
Mailing Address - Street 2:STE 335
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-7550
Mailing Address - Country:US
Mailing Address - Phone:918-307-0215
Mailing Address - Fax:918-250-7669
Practice Address - Street 1:8803 S 101ST E AVE
Practice Address - Street 2:STE 335
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-7550
Practice Address - Country:US
Practice Address - Phone:918-307-0215
Practice Address - Fax:918-250-7669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100749090BMedicaid
OKCH9137OtherRR MEDICARE
OK700522049Medicare ID - Type Unspecified