Healthcare Provider Details

I. General information

NPI: 1912407305
Provider Name (Legal Business Name): AMANDA MICHELLE GRODEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10109 E 79TH ST
TULSA OK
74133-4564
US

IV. Provider business mailing address

925 W K ST
JENKS OK
74037-2558
US

V. Phone/Fax

Practice location:
  • Phone: 918-233-9550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6665
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: