Provider Demographics
NPI:1609862093
Name:PONTIKES, LEON A (MD)
Entity type:Individual
Prefix:DR
First Name:LEON
Middle Name:A
Last Name:PONTIKES
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 1:3409 DORNOCH DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-0403
Mailing Address - Country:US
Mailing Address - Phone:580-695-5727
Mailing Address - Fax:
Practice Address - Street 1:921 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5007
Practice Address - Country:US
Practice Address - Phone:405-456-3409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48519208600000X
OK22527208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
020051475OtherRAILROAD MEDICARE
OK442172681001OtherBCBS-LAWTON
AZ871971Medicaid
OK100127100AMedicaid
OK347459110OtherDOL
OK7922317OtherAETNA
AZZ162742Medicare PIN
OK347459110OtherDOL
OK100127100AMedicaid