Provider Demographics
NPI:1912935644
Name:ATHERTON, JUSTIN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:THOMAS
Last Name:ATHERTON
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 1:1725 E 19TH ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5472
Mailing Address - Country:US
Mailing Address - Phone:918-301-2505
Mailing Address - Fax:918-744-3633
Practice Address - Street 1:1725 E 19TH ST
Practice Address - Street 2:SUITE 800
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5472
Practice Address - Country:US
Practice Address - Phone:918-301-2505
Practice Address - Fax:918-744-3633
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19797208600000X, 2086S0127X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100131760AMedicaid
OK020045078OtherRAILROAD MEDICARE
OK100131760AMedicaid
OK020045078OtherRAILROAD MEDICARE
OK$$$$$$$$$Medicare PIN