Provider Demographics
NPI:1053389833
Name:PADDACK, GARY L (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:PADDACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 ARLINGTON CTR
Mailing Address - Street 2:PMB 224
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2883
Mailing Address - Country:US
Mailing Address - Phone:580-436-2262
Mailing Address - Fax:580-272-0186
Practice Address - Street 1:902 ARLINGTON CTR
Practice Address - Street 2:PMB 224
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2883
Practice Address - Country:US
Practice Address - Phone:580-436-2262
Practice Address - Fax:580-272-0186
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK12905207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100143120BMedicaid
OK100143120BMedicaid
OK248415401Medicare PIN