Provider Demographics
NPI:1043523566
Name:GRACE MATA RUIDERA, M.D., P.C.
Entity type:Organization
Organization Name:GRACE MATA RUIDERA, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:MATA
Authorized Official - Last Name:RUIDERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-732-3990
Mailing Address - Street 1:8121 NATIONAL AVE
Mailing Address - Street 2:SUITE 309
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-7530
Mailing Address - Country:US
Mailing Address - Phone:405-732-3990
Mailing Address - Fax:
Practice Address - Street 1:8121 NATIONAL AVE
Practice Address - Street 2:SUITE 309
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-7530
Practice Address - Country:US
Practice Address - Phone:405-732-3990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19279207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty