Provider Demographics
NPI:1669506507
Name:LESA J BETHEL MULLIGAN MD PC
Entity type:Organization
Organization Name:LESA J BETHEL MULLIGAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-364-0643
Mailing Address - Street 1:1139 36TH AVE NW STE 100
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4104
Mailing Address - Country:US
Mailing Address - Phone:405-364-0643
Mailing Address - Fax:405-364-0502
Practice Address - Street 1:1139 36TH AVE NW STE 100
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4104
Practice Address - Country:US
Practice Address - Phone:405-364-0643
Practice Address - Fax:405-364-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100131240BOtherSOONERCARE
OK100131240BMedicaid