Healthcare Provider Details

I. General information

NPI: 1154680056
Provider Name (Legal Business Name): TILLMAN HUDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10901 E 48TH ST
TULSA OK
74146-5830
US

IV. Provider business mailing address

10901 E 48TH ST
TULSA OK
74146-5830
US

V. Phone/Fax

Practice location:
  • Phone: 918-749-8765
  • Fax: 918-392-2155
Mailing address:
  • Phone: 918-749-8765
  • Fax: 918-392-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number565314
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number32187
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: