Provider Demographics
NPI:1639137953
Name:TYTLE, TIMOTHY LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LAWRENCE
Last Name:TYTLE
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:PO BOX 95818
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73143-5818
Mailing Address - Country:US
Mailing Address - Phone:405-632-2323
Mailing Address - Fax:405-631-9315
Practice Address - Street 1:4625 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3831
Practice Address - Country:US
Practice Address - Phone:405-632-2323
Practice Address - Fax:405-631-9315
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK114802085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100213590BMedicaid
OK249323503Medicare PIN
OK100213590BMedicaid