Provider Demographics
NPI:1093713331
Name:TKACH, THOMAS KELLY (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:KELLY
Last Name:TKACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9600 BROADWAY EXT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-7408
Mailing Address - Country:US
Mailing Address - Phone:405-230-9000
Mailing Address - Fax:405-230-9157
Practice Address - Street 1:9600 BROADWAY EXT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-7408
Practice Address - Country:US
Practice Address - Phone:405-230-9000
Practice Address - Fax:405-230-9477
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17380207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100095900AMedicaid
OK200022041OtherRAILROAD MEDICARE
G00844Medicare UPIN