Healthcare Provider Details

I. General information

NPI: 1295790459
Provider Name (Legal Business Name): SHRIKRISHNA V VAIDYA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FAIRVIEW ST 10
PONCA CITY OK
74601
US

IV. Provider business mailing address

400 FAIRVIEW ST 10
PONCA CITY OK
74601
US

V. Phone/Fax

Practice location:
  • Phone: 580-762-7734
  • Fax: 580-762-6914
Mailing address:
  • Phone: 580-762-7734
  • Fax: 580-762-6914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number16078
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: