Provider Demographics
NPI:1104886209
Name:TWIDALE, NICHOLAS (MD,PHD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:TWIDALE
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 NW 85TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-3385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 W AVENUE A
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-3901
Practice Address - Country:US
Practice Address - Phone:580-225-6220
Practice Address - Fax:580-225-6399
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17189207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100103330AMedicaid
OK23J611501Medicare Oscar/Certification
OK23J611501Medicare PIN