Provider Demographics
NPI:1750390886
Name:LAST, ALFRED (MD)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:LAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 NW 56TH
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:405-947-5595
Mailing Address - Fax:405-947-5417
Practice Address - Street 1:3435 NW 56TH
Practice Address - Street 2:SUITE 1000
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112
Practice Address - Country:US
Practice Address - Phone:405-947-5595
Practice Address - Fax:405-947-5417
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8565207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK00014040AMedicaid
OK741619257001OtherBCBS
OK741619257OtherTRICARE
C95156Medicare UPIN