Healthcare Provider Details

I. General information

NPI: 1639137953
Provider Name (Legal Business Name): TIMOTHY LAWRENCE TYTLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4625 S WESTERN AVE
OKLAHOMA CITY OK
73109-3831
US

IV. Provider business mailing address

PO BOX 95818
OKLAHOMA CITY OK
73143-5818
US

V. Phone/Fax

Practice location:
  • Phone: 405-632-2323
  • Fax: 405-631-9315
Mailing address:
  • Phone: 405-632-2323
  • Fax: 405-631-9315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number11480
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: