Provider Demographics
NPI:1831176916
Name:DODD, MARYELLEN LEANN (MD)
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:LEANN
Last Name:DODD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6406 N SANTA FE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-9117
Mailing Address - Country:US
Mailing Address - Phone:405-840-3793
Mailing Address - Fax:405-840-3794
Practice Address - Street 1:6406 N SANTA FE AVE STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-9117
Practice Address - Country:US
Practice Address - Phone:405-840-3793
Practice Address - Fax:405-840-3794
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK243682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200081020AMedicaid
MN054978900Medicaid
OK200081020AMedicaid
MN260002088Medicare ID - Type Unspecified
OK243616601Medicare PIN
MN260050188Medicare ID - Type UnspecifiedRAILROAD