1982743787 NPI number — DR. COREY E PONDER M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982743787 NPI number — DR. COREY E PONDER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PONDER
Provider First Name:
COREY
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982743787
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 N LEE AVE STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73103-2612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-218-2530
Provider Business Mailing Address Fax Number:
405-218-2535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13401 N. WESTERN AVE.
Provider Second Line Business Practice Location Address:
STE. 301
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-478-7111
Provider Business Practice Location Address Fax Number:
405-478-7112
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  22884 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0114X , with the licence number: 22884 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1578658035 . This is a "OKLAHOMA SPORTS AND ORTHOPEDICS INSTITUTE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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