Provider Demographics
NPI:1134105984
Name:DEARDORFF, MAX A (MD)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:A
Last Name:DEARDORFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:STE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3310
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:918-488-6010
Practice Address - Street 1:3902 E 51ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3606
Practice Address - Country:US
Practice Address - Phone:918-665-3050
Practice Address - Fax:918-610-5383
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7462207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$PMedicare PIN
OKC94839Medicare UPIN