Provider Demographics
NPI:1932595576
Name:DOMEK, KAITLIN PAIGE
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:PAIGE
Last Name:DOMEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE STE 1400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4735 E 91ST ST STE 200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-2806
Practice Address - Country:US
Practice Address - Phone:918-794-4788
Practice Address - Fax:918-794-4789
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK38360208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery