1790858959 NPI number — DR. JERRY L. OESTMANN PH.D.

Table of content: KATIE LYNN SHOCKLING (NPI 1194239475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790858959 NPI number — DR. JERRY L. OESTMANN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OESTMANN
Provider First Name:
JERRY
Provider Middle Name:
L.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

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:
1790858959
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1730 DUNLAWTON AVE
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32127-8985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-957-3905
Provider Business Mailing Address Fax Number:
386-402-8992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1730 DUNLAWTON AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32127-8985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-957-3905
Provider Business Practice Location Address Fax Number:
386-402-8992
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  188 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 396 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 620 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: PY9026 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 47052851500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47052851509 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 68505B002 . This is a "TRICARE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 345680000 . This is a "MAGELLAN MIS ADOL GT" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 47075636998 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80023 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 10025208600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81118 . This is a "BCBS INDIVIDUAL PROVIDER NUMBER" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 10025208000 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 250307 . This is a "MIDLANDS INS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 098935 . This is a "MEDICARE FSI PTAN GROUP NUMBER" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 1002550710 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025668200 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 345680000 . This is a "MAGELLAN MIS GT SITE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 349507000 . This is a "MAGELLAN MIS WOMEN'S GT" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 47052851502 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47052851503 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85731 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 47052851581 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025208700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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