Basic Information
Provider Information | |||||||||
NPI: | 1447432950 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WETZ | ||||||||
FirstName: | RANDALL | ||||||||
MiddleName: | COLIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1515 N HARVARD AVE | ||||||||
Address2: | SUITE E | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741154957 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9188326051 | ||||||||
FaxNumber: | 9188306055 | ||||||||
Practice Location | |||||||||
Address1: | 1705 E 19TH ST | ||||||||
Address2: | SUITE 302 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741045405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187487585 | ||||||||
FaxNumber: | 9187487539 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/27/2007 | ||||||||
LastUpdateDate: | 07/09/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4569 | OK | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 4569 | OK | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 200183310A | 05 | OK |   | MEDICAID |