Provider Demographics
NPI:1306824651
Name:TARKENTON, TOM ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:ALLEN
Last Name:TARKENTON
Suffix:
Gender:M
Credentials:DO
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 2440
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-7440
Mailing Address - Country:US
Mailing Address - Phone:817-599-1780
Mailing Address - Fax:817-599-1781
Practice Address - Street 1:713 E ANDERSON ST
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5705
Practice Address - Country:US
Practice Address - Phone:817-599-1780
Practice Address - Fax:817-599-1781
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4552207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D2803Medicare PIN
TXF67982Medicare UPIN