Provider Demographics
NPI:1871534024
Name:PHILLIPS, TERRELL R (DO)
Entity type:Individual
Prefix:
First Name:TERRELL
Middle Name:R
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0357
Mailing Address - Country:US
Mailing Address - Phone:405-775-9350
Mailing Address - Fax:405-775-9360
Practice Address - Street 1:401 SW 80TH ST
Practice Address - Street 2:BLDG D STE 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-8122
Practice Address - Country:US
Practice Address - Phone:405-601-4227
Practice Address - Fax:405-601-4237
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2427174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100089860AMedicaid
OK050031732OtherMEDICARE RR
OK050020190OtherMEDICARE RR
OK050020190OtherMEDICARE RR
OK100089860AMedicaid
OK248307901Medicare PIN
OK$$$$$$$$$004OtherBC/BS
OK100089860AMedicaid