Provider Demographics
NPI:1558321489
Name:PEDULLA, DOMINIC M (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:M
Last Name:PEDULLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3300 NW 56TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4538
Mailing Address - Country:US
Mailing Address - Phone:405-947-2228
Mailing Address - Fax:405-947-2307
Practice Address - Street 1:3300 NW 56TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4538
Practice Address - Country:US
Practice Address - Phone:405-947-2228
Practice Address - Fax:405-947-2307
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK17642207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
110093997OtherRR MEDICARE
OK100012360AMedicaid
110093997OtherRR MEDICARE
OK100012360AMedicaid