Healthcare Provider Details

I. General information

NPI: 1821894759
Provider Name (Legal Business Name): MADISON DJURIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2025
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 LIBERTY LN
EDMOND OK
73034-9432
US

IV. Provider business mailing address

22163 COUNTY STREET 2700
GRACEMONT OK
73042-9513
US

V. Phone/Fax

Practice location:
  • Phone: 102-940-5548
  • Fax:
Mailing address:
  • Phone: 570-242-0605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: