Provider Demographics
NPI:1619962248
Name:TIMMONS, CLIFF
Entity Type:Individual
Prefix:
First Name:CLIFF
Middle Name:
Last Name:TIMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 N LANSING AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-5907
Mailing Address - Country:US
Mailing Address - Phone:918-587-2171
Mailing Address - Fax:918-582-0529
Practice Address - Street 1:1334 N LANSING AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-5907
Practice Address - Country:US
Practice Address - Phone:918-587-2171
Practice Address - Fax:918-582-0529
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK00689341247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK371803OtherMEDICARE
OKWCDPGMedicare ID - Type Unspecified