Provider Demographics
NPI:1063621381
Name:JEWELL, COTY WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:COTY
Middle Name:WAYNE
Last Name:JEWELL
Suffix:
Gender:M
Credentials:MD
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 1:5224 E I 240 SERVICE RD STE 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-2607
Practice Address - Country:US
Practice Address - Phone:405-608-3800
Practice Address - Fax:405-242-5918
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK30973207RC0001X
TXL6441207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX265332ZGS0Medicare PIN
8K8575Medicare PIN
TXPENDINGOtherRR MEDICARE
TX195540301Medicaid