Provider Demographics
NPI:1982680757
Name:DUTTON-GADDIS, JONELLE G (DO)
Entity Type:Individual
Prefix:DR
First Name:JONELLE
Middle Name:G
Last Name:DUTTON-GADDIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10505 E. 91ST ST SOUTH
Mailing Address - Street 2:STE 201
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133
Mailing Address - Country:US
Mailing Address - Phone:918-307-3250
Mailing Address - Fax:918-307-3251
Practice Address - Street 1:10505 E. 91ST ST. SOUTH
Practice Address - Street 2:STE 201
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133
Practice Address - Country:US
Practice Address - Phone:918-307-3250
Practice Address - Fax:918-307-3251
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3026207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
244414504Medicare PIN
OKF86045Medicare UPIN
OK244414504Medicare PIN
F86045Medicare UPIN