Provider Demographics
NPI:1710925680
Name:TYRRELL, MICKEY R (MD)
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:R
Last Name:TYRRELL
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 1:803 N FOREMAN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-1412
Mailing Address - Country:US
Mailing Address - Phone:918-256-2261
Mailing Address - Fax:918-256-2304
Practice Address - Street 1:803 N FOREMAN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-1412
Practice Address - Country:US
Practice Address - Phone:918-256-2261
Practice Address - Fax:918-256-2304
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK22897207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200056320BMedicaid
OK200056320BMedicaid
OK245533203Medicare ID - Type Unspecified