Healthcare Provider Details

I. General information

NPI: 1689679813
Provider Name (Legal Business Name): JAY E LEEMASTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 S TELEPHONE RD
MOORE OK
73160-2937
US

IV. Provider business mailing address

2909 S TELEPHONE RD
MOORE OK
73160-2937
US

V. Phone/Fax

Practice location:
  • Phone: 405-799-7510
  • Fax: 405-799-4742
Mailing address:
  • Phone: 405-799-7510
  • Fax: 405-799-4742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number13242
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: