Provider Demographics
NPI:1720074255
Name:SMALL, TINA C (MD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:C
Last Name:SMALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:C
Other - Last Name:BEATY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4301 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503-4472
Mailing Address - Country:US
Mailing Address - Phone:580-558-8497
Mailing Address - Fax:580-429-0819
Practice Address - Street 1:4301 WILSON ST
Practice Address - Street 2:
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-4472
Practice Address - Country:US
Practice Address - Phone:580-558-8497
Practice Address - Fax:580-558-3323
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24054208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00166228OtherRAILROAD MEDICARE
OK487023200OtherDOL
OK200038730AMedicaid
OK7664685OtherAETNA
P00166228OtherRAILROAD MEDICARE
I19329Medicare UPIN