Provider Demographics
NPI:1538177225
Name:D BRENT TIPTON M D INC
Entity type:Organization
Organization Name:D BRENT TIPTON M D INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOY
Authorized Official - Middle Name:A
Authorized Official - Last Name:COSTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-329-2390
Mailing Address - Street 1:PO BOX 973
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-0973
Mailing Address - Country:US
Mailing Address - Phone:405-329-2390
Mailing Address - Fax:405-329-0486
Practice Address - Street 1:5100 N BROOKLINE AVE
Practice Address - Street 2:SUITE 530
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3623
Practice Address - Country:US
Practice Address - Phone:405-604-6652
Practice Address - Fax:405-604-6653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18762208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK44456086901OtherBC/BS
OK100112170AMedicaid
OK44456086901OtherBC/BS
OKF30437Medicare UPIN