Healthcare Provider Details

I. General information

NPI: 1780634816
Provider Name (Legal Business Name): JERRY DAVID WHATLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 GRAND AVE
ARDMORE OK
73401-4338
US

IV. Provider business mailing address

936 DEESE RD
ARDMORE OK
73401-9315
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-3300
  • Fax: 580-223-3320
Mailing address:
  • Phone: 580-224-9035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number19096
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: