Healthcare Provider Details

I. General information

NPI: 1518935865
Provider Name (Legal Business Name): THEODORE TOLENTINO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 NW EXPRESSWAY 4TH FLOOR NICU
OKLAHOMA CITY OK
73112-4481
US

IV. Provider business mailing address

4716 TAMARISK DR
OKLAHOMA CITY OK
73142-5125
US

V. Phone/Fax

Practice location:
  • Phone: 405-949-6051
  • Fax: 405-949-6977
Mailing address:
  • Phone: 405-751-5175
  • Fax: 405-751-5175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number13674
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number1999134622
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25MA03754400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: