Provider Demographics
NPI:1194735407
Name:PENDLETON, BRUCE D (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:PENDLETON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 960394
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0001
Mailing Address - Country:US
Mailing Address - Phone:580-548-1367
Mailing Address - Fax:580-548-1583
Practice Address - Street 1:620 S MADISON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-7273
Practice Address - Country:US
Practice Address - Phone:580-616-7605
Practice Address - Fax:580-616-7626
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK13141207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100824270BMedicaid
OKC 95343Medicare UPIN
OK100824270BMedicaid