Healthcare Provider Details

I. General information

NPI: 1144303629
Provider Name (Legal Business Name): MEASE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

659 S 14TH ST
JAY OK
74346
US

IV. Provider business mailing address

PO BOX 780
JAY OK
74346-0780
US

V. Phone/Fax

Practice location:
  • Phone: 918-253-6418
  • Fax: 918-253-4066
Mailing address:
  • Phone: 918-253-6418
  • Fax: 918-253-4066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16931
License Number StateOK

VIII. Authorized Official

Name: DR. DARRELL R MEASE
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: MD
Phone: 918-253-6418