Provider Demographics
NPI:1164571436
Name:GARY PADDACK MD
Entity Type:Organization
Organization Name:GARY PADDACK MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PADDACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-436-2262
Mailing Address - Street 1:902 ARLINGTON CTR
Mailing Address - Street 2:PMB 224
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2883
Mailing Address - Country:US
Mailing Address - Phone:580-436-2262
Mailing Address - Fax:580-272-0186
Practice Address - Street 1:902 ARLINGTON CTR
Practice Address - Street 2:PMB 224
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2883
Practice Address - Country:US
Practice Address - Phone:580-436-2262
Practice Address - Fax:580-272-0186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200034360AMedicaid
OK800522357Medicare PIN