Provider Demographics
NPI:1134257231
Name:COLON AND RECTAL SURGERY OF OKLAHOMA, P.C.
Entity type:Organization
Organization Name:COLON AND RECTAL SURGERY OF OKLAHOMA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-948-0640
Mailing Address - Street 1:3433 NW 56TH ST
Mailing Address - Street 2:SUITE 760
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4461
Mailing Address - Country:US
Mailing Address - Phone:405-948-0640
Mailing Address - Fax:405-948-1753
Practice Address - Street 1:3433 NW 56TH ST
Practice Address - Street 2:SUITE 760
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4461
Practice Address - Country:US
Practice Address - Phone:405-948-0640
Practice Address - Fax:405-948-1753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK880522025OtherMEDICARE PTAN
OK100748380AMedicaid
OK100748380AMedicaid