Healthcare Provider Details

I. General information

NPI: 1093711053
Provider Name (Legal Business Name): JAYSON D AVENMARG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 WALL STREET
POTEAU OK
74953
US

IV. Provider business mailing address

PO BOX 689
POTEAU OK
74953
US

V. Phone/Fax

Practice location:
  • Phone: 918-647-8635
  • Fax: 918-635-3191
Mailing address:
  • Phone: 918-647-8635
  • Fax: 918-635-3191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA65237
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number27369
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: