Provider Demographics
NPI:1366722712
Name:BOATWRIGHT, BRIAN A (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:A
Last Name:BOATWRIGHT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8110 S YALE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-2210
Mailing Address - Country:US
Mailing Address - Phone:918-794-2003
Mailing Address - Fax:918-794-2010
Practice Address - Street 1:8110 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-2210
Practice Address - Country:US
Practice Address - Phone:918-794-2003
Practice Address - Fax:918-794-2010
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1144103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1295091411OtherMEDICARE GROUP NPI
OK200463840AMedicaid