Provider Demographics
NPI:1619057551
Name:NORTHEASTERN OKLAHOMA UROLOGY, P.C.
Entity Type:Organization
Organization Name:NORTHEASTERN OKLAHOMA UROLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:
Authorized Official - Last Name:TINGLEAF, M.D.
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-341-1311
Mailing Address - Street 1:201 W BLUE STARR DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017
Mailing Address - Country:US
Mailing Address - Phone:918-341-1311
Mailing Address - Fax:918-342-1634
Practice Address - Street 1:201 W BLUE STARR DRIVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017
Practice Address - Country:US
Practice Address - Phone:918-341-1311
Practice Address - Fax:918-342-1634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23509174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH47200Medicare UPIN