Provider Demographics
NPI:1447399415
Name:PONDER, MICHELLE M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:PONDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3013 LAMOND HILL AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6980
Mailing Address - Country:US
Mailing Address - Phone:405-361-9042
Mailing Address - Fax:
Practice Address - Street 1:4500 S GARNETT RD STE 300
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5238
Practice Address - Country:US
Practice Address - Phone:918-935-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK228832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200130260AMedicaid
OK200130260AMedicaid
OKOK404351Medicare PIN