Basic Information
| Provider Information | |||||||||
| NPI: | 1619919487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TODD | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4716 W URBANA ST | ||||||||
| Address2: | STE 211 | ||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740126157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187104112 | ||||||||
| FaxNumber: | 9187104118 | ||||||||
| Practice Location | |||||||||
| Address1: | 4716 W URBANA ST STE 211 | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740126157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1871041129 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 20778 | OK | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 20778 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100132190C | 05 | OK | MEDICAID |