Provider Demographics
NPI:1518935865
Name:TOLENTINO, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:TOLENTINO
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 1:4716 TAMARISK DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-5125
Mailing Address - Country:US
Mailing Address - Phone:405-751-5175
Mailing Address - Fax:405-751-5175
Practice Address - Street 1:3300 NW EXPRESSWAY
Practice Address - Street 2:4TH FLOOR NICU
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4481
Practice Address - Country:US
Practice Address - Phone:405-949-6051
Practice Address - Fax:405-949-6977
Is Sole Proprietor?:No
Enumeration Date:2006-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK136742080N0001X
MO19991346222080N0001X
NJ25MA037544002080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G93104Medicare UPIN