Southern Oklahoma Urology, Inc

Primary specialty

Medical Specialty Clinic/CenterTaxonomy code 261QM2500X

Legal business name

SOUTHERN OKLAHOMA UROLOGY, INC

Practice address

1414 Arlington St
Suite 2300
Ada, OK 74820-2643

Phone

(580) 332-0112

Fax

(580) 332-1005

NPI assigned

Sep 18, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Glen E Diacon Jr., MDNPI 1588659957

Title

President

Phone

(580) 332-0112

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in OK

Enrollment records 1

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Glen Edward Diacon Jr., MD

  • Specialist
  • Ada, OK
  • NPI 1588659957
  Medicare reassignment Care Compare group NPD Authorized official
• Mark C Leu, PA-C

  • Medical Physician Assistant
  • Ada, OK
  • NPI 1376538744
  Medicare reassignment Care Compare group
• Phillip Tyler Fuller, M.D.

  • Urology Physician
  • Ada, OK
  • NPI 1871720300
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1190073600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1190073600000",
    "number": "1528254109",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1414 ARLINGTON ST",
            "address_2": "SUITE 2300",
            "city": "ADA",
            "state": "OK",
            "postal_code": "748202643",
            "telephone_number": "580-332-0112",
            "fax_number": "580-332-1005"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1414 ARLINGTON ST",
            "address_2": "SUITE 2300",
            "city": "ADA",
            "state": "OK",
            "postal_code": "748202643",
            "telephone_number": "580-332-0112",
            "fax_number": "580-332-1005"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN OKLAHOMA UROLOGY, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-09-18",
        "last_updated": "2007-09-18",
        "status": "A",
        "authorized_official_last_name": "DIACON",
        "authorized_official_first_name": "GLEN",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "580-332-0112",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": "OK",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Southern Oklahoma Lifeline LLC
• Southern Oklahoma Pathology Assoc., Inc.
• Southern Oklahoma Pediatrics Inc
• Southern Oklahoma Psychological Associates Inc.
• Southern Oklahoma Treatment Serices, Inc.
• Southwest Medical Specialist
• Sovereign Family Clinic, LLC (Sovereign Family Practice Clinic)
• Bill Larue Spencer, CRNA
• Elyse Elizabeth Bowen Splichal, DC
• Linda Louise Spooner, APRN

• Medical Specialty Clinic/Center in Ada, OK
• Providers in Ada, OK by specialty
• Medical Specialty Clinic/Center in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 18, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.