Basic Information
| Provider Information | |||||||||
| NPI: | 1720151707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODRUFF | ||||||||
| FirstName: | CONCHITA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 S YALE AVE | ||||||||
| Address2: | STE 1200 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184886687 | ||||||||
| FaxNumber: | 9184886098 | ||||||||
| Practice Location | |||||||||
| Address1: | 1245 S UTICA AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185792229 | ||||||||
| FaxNumber: | 9185792239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 23123 | OK | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 20087640A | 05 | OK | MEDICAID | 244534202 | 01 | OK | MEDICARE PIN # | OTHER | 0612509 | 01 | OK | CIGNA | OTHER | 200302607 | 01 | OK | TAX ID | OTHER | OKA105880 | 01 | OK | MEDICARE PTAN | OTHER | 100224210C | 05 | OK | MEDICAID |