Healthcare Provider Details

I. General information

NPI: 1326989658
Provider Name (Legal Business Name): MAX GIOVANNI GONDOLFO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2432 W NEW ORLEANS ST
BROKEN ARROW OK
74011-1590
US

IV. Provider business mailing address

6105 W BIRMINGHAM CIR
BROKEN ARROW OK
74011-1478
US

V. Phone/Fax

Practice location:
  • Phone: 918-938-1330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4705
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: