Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0208X | Pediatric Infectious Diseases | 10979 | OK |
NPI | 1467420703 |
---|---|
Provider Name | Venusto H San Joaquin |
First Address | Oklahoma City, OK 73117-1039 |
Second Address | Oklahoma City, OK 73104-5008 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/03/2006 |
Last Update Date | 08/07/2007 |