Provider Demographics
NPI:1609817246
Name:POLLOCK, THEODORE W (DO)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:W
Last Name:POLLOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10109 E 79TH STREET
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133
Mailing Address - Country:US
Mailing Address - Phone:918-286-5000
Mailing Address - Fax:918-249-7514
Practice Address - Street 1:10109 E. 79TH STREET
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133
Practice Address - Country:US
Practice Address - Phone:918-286-5000
Practice Address - Fax:918-249-7514
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-2304207RH0003X
OK4678207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0370790Medicaid
OHPO0449141Medicare ID - Type UnspecifiedMEDICARE NUMBER
OH0370790Medicaid