Healthcare Provider Details

I. General information

NPI: 1851555239
Provider Name (Legal Business Name): TYSON RICHARD TRIMBLE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E 13TH ST SUITE 104
GROVE OK
74344-2975
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE 280
OKLAHOMA CITY OK
73112-5556
US

V. Phone/Fax

Practice location:
  • Phone: 918-786-3391
  • Fax: 918-786-7264
Mailing address:
  • Phone: 918-786-3391
  • Fax: 918-786-7264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4694
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: