Provider Demographics
NPI:1386698728
Name:JAISWAL, DEEPAK S (MD)
Entity type:Individual
Prefix:
First Name:DEEPAK
Middle Name:S
Last Name:JAISWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:702 BRYAN DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-7000
Mailing Address - Country:US
Mailing Address - Phone:580-924-4704
Mailing Address - Fax:580-924-6001
Practice Address - Street 1:702 BRYAN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-7000
Practice Address - Country:US
Practice Address - Phone:580-924-4704
Practice Address - Fax:580-924-6001
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2011-04-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK18645207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100207270BOtherINDIVIDUAL MK NUMBER
OK100207270AMedicaid
OK242323400OtherINDIVIDUAL MC NUMBER
OK242323400OtherINDIVIDUAL MC NUMBER