Provider Demographics
NPI:1760607485
Name:TILLINGHAST, JON DALTON (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:DALTON
Last Name:TILLINGHAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:600 NW 4TH ST
Mailing Address - Street 2:#211
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-1638
Mailing Address - Country:US
Mailing Address - Phone:405-235-5685
Mailing Address - Fax:
Practice Address - Street 1:1000 NE 10TH ST
Practice Address - Street 2:OKLAHOMA STATE DEPARTMENT OF HEALTH TB DIVISION
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1299
Practice Address - Country:US
Practice Address - Phone:405-271-4060
Practice Address - Fax:405-271-6680
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK84892083P0901X
TXD35332083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDEAAT8912138OtherNARCOTIC LICENSE #