Provider Demographics
NPI:1811213879
Name:PEARISH, LONI DAWN (DO)
Entity type:Individual
Prefix:MRS
First Name:LONI
Middle Name:DAWN
Last Name:PEARISH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13163 S OAK ST
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-2323
Mailing Address - Country:US
Mailing Address - Phone:918-291-2022
Mailing Address - Fax:
Practice Address - Street 1:1111 S SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5440
Practice Address - Country:US
Practice Address - Phone:918-619-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
OK5108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200345220BMedicaid
OK200468380CMedicaid
OK200468380CMedicaid