Provider Demographics
NPI:1902671233
Name:MCCARGO, OCTAVIA T
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:T
Last Name:MCCARGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 E 142ND PL
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-3581
Mailing Address - Country:US
Mailing Address - Phone:918-933-9549
Mailing Address - Fax:
Practice Address - Street 1:5310 E 31ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5012
Practice Address - Country:US
Practice Address - Phone:918-587-9471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator