Provider Demographics
NPI:1356377824
Name:GOROSPE, LUIS VENTURA (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:VENTURA
Last Name:GOROSPE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1200 W CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4624
Mailing Address - Country:US
Mailing Address - Phone:918-485-1240
Mailing Address - Fax:918-485-9701
Practice Address - Street 1:705 W QUEENS ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-1767
Practice Address - Country:US
Practice Address - Phone:918-252-2800
Practice Address - Fax:918-252-2888
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2013-09-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK10249208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100112850AMedicaid
OKC94982Medicare UPIN
OK$$$$$$$$$Medicare PIN