1104900554 NPI number — DONEY MEDICAL, INC.

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 1104900554 NPI number — DONEY MEDICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DONEY MEDICAL, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1104900554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 2ND AVE SW
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74354-6702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-542-8477
Provider Business Mailing Address Fax Number:
918-542-6422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 2ND AVE SW
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74354-6702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-542-8477
Provider Business Practice Location Address Fax Number:
918-542-6422
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DONEY
Authorized Official First Name:
JACK
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
918-542-8477

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  11653 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 11653 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X , with the licence number: 11653 , 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: 100209450A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100735640A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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