Healthcare Provider Details

I. General information

NPI: 1154736346
Provider Name (Legal Business Name): JOSHUA PRIDDLE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 COLONY DR
ADA OK
74820-2329
US

IV. Provider business mailing address

527 W 3RD ST
KONAWA OK
74849-1415
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-5111
  • Fax: 580-436-1159
Mailing address:
  • Phone: 580-925-3286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5800
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number5800
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: