Provider Demographics
NPI:1477665941
Name:DERSTINE, THOMAS A (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:DERSTINE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 S WATER
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066
Mailing Address - Country:US
Mailing Address - Phone:918-224-6050
Mailing Address - Fax:918-224-6029
Practice Address - Street 1:20 S WATER
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066
Practice Address - Country:US
Practice Address - Phone:918-224-6050
Practice Address - Fax:918-224-6029
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1690111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
QDBSQMedicare ID - Type Unspecified