Provider Demographics
NPI:1699072116
Name:ABODAKPI, WONDER D
Entity type:Individual
Prefix:
First Name:WONDER
Middle Name:D
Last Name:ABODAKPI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 702504
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-2504
Mailing Address - Country:US
Mailing Address - Phone:918-791-0026
Mailing Address - Fax:800-260-7966
Practice Address - Street 1:4122 W 55TH PLACE SOUTH
Practice Address - Street 2:SUITE 119
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-9108
Practice Address - Country:US
Practice Address - Phone:918-791-0026
Practice Address - Fax:800-260-7966
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK303065171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200435470BMedicaid