Provider Demographics
NPI:1376546531
Name:PETTINGELL, TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:PETTINGELL
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 1:10026 S MINGO RD STE A
Mailing Address - Street 2:PMB 234
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5717
Mailing Address - Country:US
Mailing Address - Phone:918-252-7952
Mailing Address - Fax:918-252-9218
Practice Address - Street 1:4735 E 91ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-2807
Practice Address - Country:US
Practice Address - Phone:918-252-7952
Practice Address - Fax:918-252-9218
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2012-05-29
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
OK208062081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100251620AMedicaid
OKG75926Medicare UPIN
OK100251620AMedicaid