Provider Demographics
NPI:1497815187
Name:BUMGARDNER, JOYCE LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:LOUISE
Last Name:BUMGARDNER
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 1:7919 S JOPLIN AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-9120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 E DEWEY AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4201
Practice Address - Country:US
Practice Address - Phone:918-227-2016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK130942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100135370CMedicaid
OK100135370BMedicaid
OK249600607Medicare ID - Type Unspecified
OK100135370BMedicaid