Provider Demographics
NPI:1962542142
Name:ANGELIDIS, PRODROMOS MIKE (MD)
Entity type:Individual
Prefix:
First Name:PRODROMOS
Middle Name:MIKE
Last Name:ANGELIDIS
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 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3347
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:918-488-6010
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-494-5346
Practice Address - Fax:918-494-6303
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23934207R00000X
TXN0610207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198836203Medicaid
TX198836201Medicaid
TX198836202Medicaid
TX8L5140Medicare PIN
TX198836202Medicaid
TX198836203Medicaid