Provider Demographics
NPI:1316945363
Name:MORGAN, JERRY S (M D L L C)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:S
Last Name:MORGAN
Suffix:
Gender:M
Credentials:M D L L C
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:S
Other - Last Name:MORGAN SOLE MBR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1921 STONECIPHER BLVD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820
Mailing Address - Country:US
Mailing Address - Phone:580-421-4570
Mailing Address - Fax:580-421-6283
Practice Address - Street 1:1921 STONECIPHER BLVD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3439
Practice Address - Country:US
Practice Address - Phone:580-436-3980
Practice Address - Fax:580-272-2708
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine