Provider Demographics
NPI:1376596395
Name:PODLESKI, GREGG T (DO)
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:T
Last Name:PODLESKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1 EAST CLARK BASS BLVD
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501
Mailing Address - Country:US
Mailing Address - Phone:918-421-3951
Mailing Address - Fax:918-421-6679
Practice Address - Street 1:1 E. CLARK BASS BLVD
Practice Address - Street 2:STE 210
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501
Practice Address - Country:US
Practice Address - Phone:918-421-3951
Practice Address - Fax:918-421-6679
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2024-06-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXJ7138207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034994601Medicaid
TXF42342Medicare UPIN