Provider Demographics
NPI:1225201718
Name:CHRISTIAN CARDIOVASCULAR INSTITUTE PC
Entity Type:Organization
Organization Name:CHRISTIAN CARDIOVASCULAR INSTITUTE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEDULLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-947-2228
Mailing Address - Street 1:3300 NW 56TH STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4401
Mailing Address - Country:US
Mailing Address - Phone:405-947-2228
Mailing Address - Fax:405-947-2307
Practice Address - Street 1:3300 NW 56TH STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4401
Practice Address - Country:US
Practice Address - Phone:405-947-2228
Practice Address - Fax:405-947-2307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17642207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10012360AMedicaid
DP6097OtherRAILROAD MEDICARE
OK10012360AMedicaid