Basic Information
| Provider Information | |||||||||
| NPI: | 1639137953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TYTLE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | LAWRENCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95818 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731435818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056322323 | ||||||||
| FaxNumber: | 4056319315 | ||||||||
| Practice Location | |||||||||
| Address1: | 4625 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731093831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056322323 | ||||||||
| FaxNumber: | 4056319315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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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 | 2085R0204X | 11480 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100213590B | 05 | OK | MEDICAID |