Individual
ALFRED LAST
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3435 NW 56TH, SUITE 1000, OKLAHOMA CITY, OK 73112
(405) 947-5595
(405) 947-5417
Mailing address
3435 NW 56TH, SUITE 1000, OKLAHOMA CITY, OK 73112
(405) 947-5595
(405) 947-5417
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
8565
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00014040A
—
OK
01
—
741619257
TRICARE
OK
01
—
741619257001
BCBS
OK
Enumeration date
08/07/2006
Last updated
12/22/2009
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