Provider Demographics
NPI:1578548475
Name:MANDUANO, JOEY M (DO)
Entity Type:Individual
Prefix:DR
First Name:JOEY
Middle Name:M
Last Name:MANDUANO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2219 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-1411
Mailing Address - Country:US
Mailing Address - Phone:918-749-5522
Mailing Address - Fax:918-747-5522
Practice Address - Street 1:2219 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-1411
Practice Address - Country:US
Practice Address - Phone:918-749-5522
Practice Address - Fax:918-747-5522
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK16282086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731047122001OtherBCBS OF OKLAHOMA
E11370Medicare UPIN