Provider Demographics
NPI:1902868029
Name:PENTECOST, DIANE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:PENTECOST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 S UTICA AVE
Mailing Address - Street 2:STE 217
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4909
Mailing Address - Country:US
Mailing Address - Phone:918-744-3664
Mailing Address - Fax:918-748-7688
Practice Address - Street 1:1611 S UTICA AVE
Practice Address - Street 2:STE 217
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4909
Practice Address - Country:US
Practice Address - Phone:918-744-3664
Practice Address - Fax:918-748-7688
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16158207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00335038OtherRR MEDICARE
OK100118480AMedicaid
OK100118480AMedicaid
OKP00335038OtherRR MEDICARE