1376596395 NPI number — GREGG T PODLESKI D.O.

Table of content: GREGG T PODLESKI D.O. (NPI 1376596395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376596395 NPI number — GREGG T PODLESKI D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PODLESKI
Provider First Name:
GREGG
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1376596395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 EAST CLARK BASS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCALESTER
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-421-3951
Provider Business Mailing Address Fax Number:
918-421-6679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 E. CLARK BASS BLVD
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
MCALESTER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-421-3951
Provider Business Practice Location Address Fax Number:
918-421-6679
Provider Enumeration Date:
05/19/2006

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:  J7138 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 034994601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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