Healthcare Provider Details

I. General information

NPI: 1497383558
Provider Name (Legal Business Name): JASON GRANGER BUNN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 STANTON L YOUNG BLVD # 2475
OKLAHOMA CITY OK
73104-5018
US

IV. Provider business mailing address

800 STANTON L YOUNG BLVD STE 2000
OKLAHOMA CITY OK
73104-5018
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-8469
  • Fax:
Mailing address:
  • Phone: 405-271-8469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number43024
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: