Basic Information
| Provider Information | |||||||||
| NPI: | 1518939792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3212 SW 89TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731597956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053783300 | ||||||||
| FaxNumber: | 4053783993 | ||||||||
| Practice Location | |||||||||
| Address1: | 3212 SW 89TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731597956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053783300 | ||||||||
| FaxNumber: | 4053783993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 07/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 2469 | OK | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 100147190A | 05 | OK | MEDICAID | P00040576 | 01 | OK | RAILROAD MEDICARE | OTHER |