Provider Demographics
NPI:1700040649
Name:MELINDA DANDRIDGE DO PLLC
Entity Type:Organization
Organization Name:MELINDA DANDRIDGE DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DANDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-298-5437
Mailing Address - Street 1:410 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-4135
Mailing Address - Country:US
Mailing Address - Phone:918-298-5438
Mailing Address - Fax:
Practice Address - Street 1:410 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-4135
Practice Address - Country:US
Practice Address - Phone:918-298-5438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3942261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200037860BMedicaid