Provider Demographics
NPI:1811122591
Name:PHILLIPS, MIRANDA LOGAN (DO)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LOGAN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7122 S SHERIDAN RD STE 2-335
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-2748
Mailing Address - Country:US
Mailing Address - Phone:918-809-9364
Mailing Address - Fax:
Practice Address - Street 1:9625 E 108TH PL S
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6774
Practice Address - Country:US
Practice Address - Phone:918-809-9364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-24
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-9713207P00000X
OK4945207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine