Healthcare Provider Details

I. General information

NPI: 1447281753
Provider Name (Legal Business Name): TYE WARD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DOWNING ST SUITE 214
TAHLEQUAH OK
74464-3234
US

IV. Provider business mailing address

PO BOX 751
HULBERT OK
74441-0751
US

V. Phone/Fax

Practice location:
  • Phone: 918-431-0202
  • Fax: 918-432-0203
Mailing address:
  • Phone: 918-772-3390
  • Fax: 918-432-0203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4140
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200018970A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: