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NPI Code Detail

MEDICARE: PONYA DIAGNOSTICS OF OKLAHOMA LLC

MEDICARE: PONYA DIAGNOSTICS OF OKLAHOMA LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1291U00000XClinical Medical Laboratory

General Provider Information

NPI Number : 1417816935
Entity Type Code : Organization
Provider Name (Legal Business Name) : PONYA DIAGNOSTICS OF OKLAHOMA LLC
Provider Business Mailing Address
First Line : 13 CORPORATE BLVD NE STE 250
Second Line :
City : BROOKHAVEN
State : GA
Zip : 30329-1901
Country : US
Telephone Number : 229-442-7210
Fax Number : 404-759-2019
Provider Business Practice Location Address
First Line : 6312 E 101ST ST
Second Line :
City : TULSA
State : OK
Zip : 74137-7007
Country : US
Telephone Number : 229-442-7210
Fax Number :
Authorized Official
Title or Position : OWNER
Name : MEKONNEN ABEBE
Credential :
Telephone Number : 229-442-7210
Provider Enumeration Date : 01/20/2026
Last Update Date : 01/21/2026

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Directions to “PONYA DIAGNOSTICS OF OKLAHOMA LLC ” Practice Location

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