Provider Demographics
NPI:1174767255
Name:MODEST-MCKOY, MONIQUE TISHA (MD)
Entity type:Individual
Prefix:MRS
First Name:MONIQUE
Middle Name:TISHA
Last Name:MODEST-MCKOY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-6520
Mailing Address - Country:US
Mailing Address - Phone:918-403-7066
Mailing Address - Fax:918-744-2946
Practice Address - Street 1:3400 E FRANK PHILLIPS BLVD STE 400
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2440
Practice Address - Country:US
Practice Address - Phone:183-312-5339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29720207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200489990AMedicaid
OK296123YLV0Medicare PIN