=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700040649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MELINDA DANDRIDGE DO PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2008
-----------------------------------------------------
Last Update Date | 07/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 E MAIN ST
-----------------------------------------------------
City | JENKS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74037-4135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-298-5438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 E MAIN ST
-----------------------------------------------------
City | JENKS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74037-4135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-298-5438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRICICAN
-----------------------------------------------------
Name | DR. MELINDA DANDRIDGE
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 918-298-5437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 3942
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------