Healthcare Provider Details

I. General information

NPI: 1346777620
Provider Name (Legal Business Name): POOJA MOHAN PADIGALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date: 12/18/2017
Reactivation Date: 02/19/2019

III. Provider practice location address

1145 S UTICA AVE STE 460
TULSA OK
74104-4041
US

IV. Provider business mailing address

1145 S UTICA AVE STE 460
TULSA OK
74104-4041
US

V. Phone/Fax

Practice location:
  • Phone: 918-579-5749
  • Fax: 918-579-5762
Mailing address:
  • Phone: 918-579-5749
  • Fax: 918-579-5762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2022008784
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35450
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: