Healthcare Provider Details

I. General information

NPI: 1144896051
Provider Name (Legal Business Name): JASON LAUDERDALE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 CHARTRAND CT
EDMOND OK
73034-5538
US

IV. Provider business mailing address

908 CHARTRAND CT
EDMOND OK
73034-5538
US

V. Phone/Fax

Practice location:
  • Phone: 405-408-2780
  • Fax: 405-408-2780
Mailing address:
  • Phone: 405-408-2780
  • Fax: 405-408-2780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberBP10089921
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: