Organization
WALLACE B MCLEOD III, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JESSIE MAE SHAMBRA (OFFICE MANAGER)
(405) 424-0111
Entity
Organization
Contact information
Practice address
2216 N MARTIN LUTHER KING AVE, OKLAHOMA CITY, OK 73111-2445
(405) 424-0111
Mailing address
2216 N MARTIN LUTHER KING AVE, OKLAHOMA CITY, OK 73111-2445
(405) 424-0111
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05538623602
—
OK
Enumeration date
05/27/2010
Last updated
10/17/2022
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