Healthcare Provider Details

I. General information

NPI: 1023804424
Provider Name (Legal Business Name): MONDUTA HEALTHCARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 W CHEROKEE ST STE C
WAGONER OK
74467-4629
US

IV. Provider business mailing address

1000 W ELMIRA ST
BROKEN ARROW OK
74012-0872
US

V. Phone/Fax

Practice location:
  • Phone: 918-857-9932
  • Fax:
Mailing address:
  • Phone: 918-857-9932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERNEST MAINA
Title or Position: OWNER
Credential: NP
Phone: 918-857-9932