Provider Demographics
NPI:1356190771
Name:MK DIAGNOSTIC ULTRASOUNDS LLC
Entity type:Organization
Organization Name:MK DIAGNOSTIC ULTRASOUNDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MERCADES
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLOSHA
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:918-574-1134
Mailing Address - Street 1:8400 S. KALANCHOE AVE.
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011
Mailing Address - Country:US
Mailing Address - Phone:918-574-1134
Mailing Address - Fax:
Practice Address - Street 1:8400 S. KALANCHOE AVE.
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011
Practice Address - Country:US
Practice Address - Phone:918-574-1134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile