Healthcare Provider Details

I. General information

NPI: 1366891202
Provider Name (Legal Business Name): JESSICA GAMBILL PUTMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NE 10TH ST # 5D
OKLAHOMA CITY OK
73104-5417
US

IV. Provider business mailing address

825 NE 10TH ST # 5D
OKLAHOMA CITY OK
73104-5417
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-9493
  • Fax: 405-271-4606
Mailing address:
  • Phone: 405-271-9493
  • Fax: 405-271-4606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2016018406
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number60525
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number39481
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: