Provider Demographics
NPI:1851555239
Name:TRIMBLE, TYSON RICHARD (DO)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:RICHARD
Last Name:TRIMBLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:918-786-3391
Mailing Address - Fax:918-786-7264
Practice Address - Street 1:900 E 13TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2975
Practice Address - Country:US
Practice Address - Phone:918-786-3391
Practice Address - Fax:918-786-7264
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4694207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200216420BMedicaid
OK200462050OMedicaid
OK900522214Medicare PIN
OK200462050OMedicaid
OKOKA104829Medicare PIN