Provider Demographics
NPI:1639220437
Name:DERNAIKA, TAREK A (MD)
Entity Type:Individual
Prefix:
First Name:TAREK
Middle Name:A
Last Name:DERNAIKA
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 1:4401 W MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:13313 N MERIDIAN AVE
Practice Address - Street 2:BUILDING D
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8380
Practice Address - Country:US
Practice Address - Phone:405-755-4290
Practice Address - Fax:405-755-7773
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23760207R00000X, 207RP1001X, 207RS0012X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00763891OtherRAILROAD MEDICARE
OK200105550BMedicaid
OKOK700188Medicare PIN
OK200105550BMedicaid
OKOK400969Medicare PIN