Provider Demographics
NPI:1073702221
Name:TATOM, JOHN H (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:TATOM
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:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-0030
Mailing Address - Country:US
Mailing Address - Phone:580-622-6644
Mailing Address - Fax:580-622-5061
Practice Address - Street 1:1113 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-4413
Practice Address - Country:US
Practice Address - Phone:580-622-6644
Practice Address - Fax:580-622-5061
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7333208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD35338Medicare UPIN