Provider Demographics
NPI:1518939792
Name:MOORE, TIMOTHY L (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:L
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3212 SW 89TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7956
Mailing Address - Country:US
Mailing Address - Phone:405-378-3300
Mailing Address - Fax:405-378-3993
Practice Address - Street 1:3212 SW 89TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7956
Practice Address - Country:US
Practice Address - Phone:405-378-3300
Practice Address - Fax:405-378-3993
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK2469208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100147190AMedicaid
OKP00040576OtherRAILROAD MEDICARE
OK243320901Medicare PIN
OKD38564Medicare UPIN