Healthcare Provider Details

I. General information

NPI: 1003484411
Provider Name (Legal Business Name): THAYNE MADSEN PARKER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2021
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S GARNETT RD STE 112
TULSA OK
74146-5201
US

IV. Provider business mailing address

4500 S GARNETT RD STE 112
TULSA OK
74146-5201
US

V. Phone/Fax

Practice location:
  • Phone: 918-935-3550
  • Fax: 918-935-3581
Mailing address:
  • Phone: 918-935-3550
  • Fax: 918-935-3581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number7652
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: