Provider Demographics
NPI:1629059803
Name:DEPAULA, CARL JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:JOSEPH
Last Name:DEPAULA
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 1:111 TOMMYE LN
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4173
Mailing Address - Country:US
Mailing Address - Phone:918-458-3360
Mailing Address - Fax:918-458-3511
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3360
Practice Address - Fax:918-458-3511
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45362-020207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150664001Medicaid
OK200012890AMedicaid
8HBP34Medicare ID - Type UnspecifiedMCARE PROVIDER #
OK200012890AMedicaid