Provider Demographics
NPI:1447281753
Name:WARD, TYE (DO)
Entity type:Individual
Prefix:
First Name:TYE
Middle Name:
Last Name:WARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751
Mailing Address - Street 2:
Mailing Address - City:HULBERT
Mailing Address - State:OK
Mailing Address - Zip Code:74441-0751
Mailing Address - Country:US
Mailing Address - Phone:918-772-3390
Mailing Address - Fax:918-432-0203
Practice Address - Street 1:1500 E DOWNING ST
Practice Address - Street 2:SUITE 214
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3234
Practice Address - Country:US
Practice Address - Phone:918-431-0202
Practice Address - Fax:918-432-0203
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200018970AMedicaid
OK731622831OtherEIN
H98467Medicare UPIN
OK731622831OtherEIN