Provider Demographics
NPI:1326086505
Name:EWING, TOM WALLACE (DO)
Entity Type:Individual
Prefix:DR
First Name:TOM
Middle Name:WALLACE
Last Name:EWING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1020 24TH AVE NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6341
Mailing Address - Country:US
Mailing Address - Phone:405-447-4999
Mailing Address - Fax:405-447-5608
Practice Address - Street 1:1020 24TH AVE NW
Practice Address - Street 2:SUITE 100
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6341
Practice Address - Country:US
Practice Address - Phone:405-447-4999
Practice Address - Fax:405-447-5608
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK2243207XS0106X
TXF0996207XS0106X, 207X00000X
MI5101007044207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100228970DMedicaid
OKB76197Medicare UPIN
OK0882410002Medicare NSC