Healthcare Provider Details

I. General information

NPI: 1265431522
Provider Name (Legal Business Name): JEFFREY C NEILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BRYAN DR SUITE 304
DURANT OK
74701-2156
US

IV. Provider business mailing address

1400 BRYAN DR STE 300
DURANT OK
74701-2158
US

V. Phone/Fax

Practice location:
  • Phone: 580-931-2278
  • Fax: 580-931-2274
Mailing address:
  • Phone: 580-931-2278
  • Fax: 580-931-2274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG8932
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: