Mission Street Medical Clinic Inc

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

2405 Issued in OK

Legal business name

MISSION STREET MEDICAL CLINIC INC

Practice address

615 S Mission St Ste a
Sapulpa, OK 74066-4635

Phone

(918) 224-9555

Fax

(918) 224-8001

NPI assigned

Sep 20, 2006

Last updated

Dec 30, 2010By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dianna M Willis, D.O.NPI 1376641316

Title

Doctor

Phone

(918) 224-9555

Specialties & licenses 1

Addresses

Other identifiers 2

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Dianna Marie Willis, D.O.

  • Family Medicine Physician
  • Sapulpa, OK
  • NPI 1376641316
  NPD Authorized official

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

{
    "created_epoch": "1158710400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1293667200000",
    "number": "1972600112",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "615 S MISSION ST STE A",
            "city": "SAPULPA",
            "state": "OK",
            "postal_code": "740664635",
            "telephone_number": "918-224-9555",
            "fax_number": "918-224-8001"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "615 S MISSION ST STE A",
            "city": "SAPULPA",
            "state": "OK",
            "postal_code": "740664635",
            "telephone_number": "918-224-9555",
            "fax_number": "918-224-8001"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MISSION STREET MEDICAL CLINIC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-20",
        "last_updated": "2010-12-30",
        "status": "A",
        "authorized_official_last_name": "WILLIS",
        "authorized_official_first_name": "DIANNA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "DOCTOR",
        "authorized_official_telephone_number": "918-224-9555",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OK",
            "license": "2405",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100739110A",
            "state": "OK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "C05052",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Family Medicine Physician in Sapulpa, OK
• Providers in Sapulpa, OK by specialty
• Family Medicine Physician in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 30, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.