Provider Demographics
NPI:1881717544
Name:ADA GYNECOLOGY & OBSTETRICS
Entity type:Organization
Organization Name:ADA GYNECOLOGY & OBSTETRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-436-9088
Mailing Address - Street 1:1414 ARLINGTON ST STE 1700
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2694
Mailing Address - Country:US
Mailing Address - Phone:580-436-9088
Mailing Address - Fax:580-436-0035
Practice Address - Street 1:1414 ARLINGTON ST STE 1700
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2694
Practice Address - Country:US
Practice Address - Phone:580-436-9088
Practice Address - Fax:580-436-0035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8279305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR81496Medicare UPIN
OKD35380Medicare UPIN