1659652576 NPI number — JENNIFER B. ROBERTS, MD, PLLC

Table of content: (NPI 1659652576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659652576 NPI number — JENNIFER B. ROBERTS, MD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JENNIFER B. ROBERTS, MD, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659652576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 248855
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73124-8855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-310-3843
Provider Business Mailing Address Fax Number:
405-321-5348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2413 PALMER CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORMAN
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73069-6301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-310-3843
Provider Business Practice Location Address Fax Number:
405-321-5348
Provider Enumeration Date:
09/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
405-310-3843

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  25719 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1871799619 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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