Provider Demographics
NPI:1821190174
Name:CARNINE, THADDEUS ALAN (MD)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:ALAN
Last Name:CARNINE
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 1:2017 W I 35 FRONTAGE RD STE 250
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8561
Mailing Address - Country:US
Mailing Address - Phone:405-757-3340
Mailing Address - Fax:405-757-3520
Practice Address - Street 1:2017 W I 35 FRONTAGE RD STE 250
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8561
Practice Address - Country:US
Practice Address - Phone:405-757-3340
Practice Address - Fax:405-757-3520
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22939207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200166750AMedicaid