Provider Demographics
NPI:1780705772
Name:SOUTHERN OKLAHOMA PEDIATRICS INC
Entity type:Organization
Organization Name:SOUTHERN OKLAHOMA PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TAWFIK
Authorized Official - Middle Name:Z
Authorized Official - Last Name:RAMADAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-436-2283
Mailing Address - Street 1:1214 ARLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4045
Mailing Address - Country:US
Mailing Address - Phone:580-436-2283
Mailing Address - Fax:580-436-2291
Practice Address - Street 1:1214 ARLINGTON ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4045
Practice Address - Country:US
Practice Address - Phone:580-436-2283
Practice Address - Fax:580-436-2291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11462174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100108060 AMedicaid
OK100734530 AMedicaid
OKE11792Medicare UPIN
OK100108060 AMedicaid