Provider Demographics
NPI:1356300784
Name:GONCE, MIKE E (MD)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:E
Last Name:GONCE
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 1:3333 NW 63RD ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-3710
Mailing Address - Country:US
Mailing Address - Phone:405-748-3636
Mailing Address - Fax:405-749-9421
Practice Address - Street 1:3333 NW 63RD ST
Practice Address - Street 2:SUITE 210
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-3710
Practice Address - Country:US
Practice Address - Phone:405-748-3636
Practice Address - Fax:405-749-9421
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17330174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKF11121Medicare UPIN