Provider Demographics
NPI:1316916679
Name:VANNATTA, JERRY B (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:B
Last Name:VANNATTA
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 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI 236
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-271-1515
Mailing Address - Fax:
Practice Address - Street 1:825 NE 10TH ST
Practice Address - Street 2:OUPB 4300
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5417
Practice Address - Country:US
Practice Address - Phone:405-271-3445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10842207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731069170077OtherBCBS
OK100825370DMedicaid
C95608Medicare UPIN
OK100825370DMedicaid