Provider Demographics
NPI:1326764127
Name:MUKOROMBINDO, DOUGLAS
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:MUKOROMBINDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 E MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8213
Mailing Address - Country:US
Mailing Address - Phone:405-459-7016
Mailing Address - Fax:
Practice Address - Street 1:5400 E MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8213
Practice Address - Country:US
Practice Address - Phone:405-459-7016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28214779A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily