Provider Demographics
NPI:1558312280
Name:CARDICH, PEDRO LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:PEDRO
Middle Name:LUIS
Last Name:CARDICH
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 1:3 E CLARK BASS BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4234
Mailing Address - Country:US
Mailing Address - Phone:918-421-6979
Mailing Address - Fax:918-421-8990
Practice Address - Street 1:3 E CLARK BASS BLVD STE 1
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4234
Practice Address - Country:US
Practice Address - Phone:918-421-6960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
OK215212084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100084850AMedicaid