Provider Demographics
NPI:1548221443
Name:MEDCALF, TIMOTHY W (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:MEDCALF
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 1:527 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-1415
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:
Practice Address - Street 1:301 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4607
Practice Address - Country:US
Practice Address - Phone:580-364-5111
Practice Address - Fax:580-279-1994
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0431221207RC0000X
MO2004020021207RC0000X
AZE-1653207RC0000X
TXK4954207RC0000X
OK16129207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200080110AOtherMEDICAID GROUP
OK300522226OtherMEDICARE GROUP
OK100125290BMedicaid
OK300522226OtherMEDICARE GROUP
MOE11803Medicare UPIN
PA243614502Medicare ID - Type Unspecified
OK300522226OtherMEDICARE GROUP