Provider Demographics
NPI:1639164163
Name:GRODE, TIMOTHY L (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:GRODE
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 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:13313 N MERIDIAN AVE
Practice Address - Street 2:BUILDING D
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8380
Practice Address - Country:US
Practice Address - Phone:405-755-4290
Practice Address - Fax:405-755-7773
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12230207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100187150BMedicaid
OKP00196981OtherRAILROAD MEDICARE
OK249502510Medicare ID - Type Unspecified
OKOK700206Medicare PIN
OKOK700189Medicare PIN
OKOK400695Medicare PIN
OKOK401495Medicare PIN
OK100187150BMedicaid