Basic Information
| Provider Information | |||||||||
| NPI: | 1679548572 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELDRIDGE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 SW 80TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731398123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052869465 | ||||||||
| FaxNumber: | 4052869462 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 NW 9TH ST STE 6200 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052324211 | ||||||||
| FaxNumber: | 4052323767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 21880 | OK | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100041900A | 05 | OK | MEDICAID |