Provider Demographics
NPI:1962429787
Name:DOLAN, C TERRENCE (MD)
Entity type:Individual
Prefix:
First Name:C
Middle Name:TERRENCE
Last Name:DOLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4142 S MINGO RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-3632
Mailing Address - Country:US
Mailing Address - Phone:918-744-2553
Mailing Address - Fax:918-744-3482
Practice Address - Street 1:4142 S MINGO RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-3632
Practice Address - Country:US
Practice Address - Phone:918-744-2553
Practice Address - Fax:918-744-3482
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12544207ZP0102X, 207ZM0300X
KS04-13816207ZP0102X
NE10817207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZM0300XAllopathic & Osteopathic PhysiciansPathologyMedical Microbiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100258090BMedicaid
OK9791Medicaid
KS100158930AMedicaid
KS100158930AMedicaid