MEDICARE: MARYELLEN LEANN DODD M.D.

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
1	2084P0800X	Psychiatry Physician	24368	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831176916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYELLEN LEANN DODD M.D.

Provider Business Mailing Address
First Line	:	6406 N SANTA FE AVE STE A
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-9117
Country	:	US
Telephone Number	:	405-840-3793
Fax Number	:	405-840-3794

Provider Business Practice Location Address
First Line	:	6406 N SANTA FE AVE STE A
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-9117
Country	:	US
Telephone Number	:	405-840-3793
Fax Number	:	405-840-3794

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	07/15/2022

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