Provider Demographics
NPI:1710041280
Name:GOFORTH, THOMAS FRED (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:FRED
Last Name:GOFORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7410 S MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73169-6908
Mailing Address - Country:US
Mailing Address - Phone:405-680-4074
Mailing Address - Fax:405-680-4035
Practice Address - Street 1:7410 S MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73169-6908
Practice Address - Country:US
Practice Address - Phone:405-680-4074
Practice Address - Fax:405-680-4035
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK12260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK039135Medicare UPIN