Provider Demographics
NPI:1881624153
Name:TINGLEAF, CLARK JIRO (MD)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:JIRO
Last Name:TINGLEAF
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10512 N 110TH EAST AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-6636
Mailing Address - Country:US
Mailing Address - Phone:918-376-8926
Mailing Address - Fax:918-377-8936
Practice Address - Street 1:10512 N 110TH EAST AVE
Practice Address - Street 2:STE 200
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-6636
Practice Address - Country:US
Practice Address - Phone:918-376-8926
Practice Address - Fax:918-377-8936
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2019-09-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK23509208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200015250BMedicaid
OKH47200Medicare UPIN
OK200015250BMedicaid