Provider Demographics
NPI:1912181348
Name:OKMULGEE PEDIATRICS
Entity Type:Organization
Organization Name:OKMULGEE PEDIATRICS
Other - Org Name:OKMULGEE PEDIATRICS & FAMILY CARE, L.L.P.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAILA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-756-8371
Mailing Address - Street 1:916 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-4724
Mailing Address - Country:US
Mailing Address - Phone:918-756-8371
Mailing Address - Fax:918-758-3437
Practice Address - Street 1:916 E 8TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-4724
Practice Address - Country:US
Practice Address - Phone:918-756-8371
Practice Address - Fax:918-758-3437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10783174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100708210CMedicaid