Healthcare Provider Details

I. General information

NPI: 1134204852
Provider Name (Legal Business Name): WILLIAM JACK MYERS JR. D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E DOWNING ST
TAHLEQUAH OK
74464-3324
US

IV. Provider business mailing address

610 E SEATTLE PL
BROKEN ARROW OK
74012-8107
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-0641
  • Fax:
Mailing address:
  • Phone: 918-606-1984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number4218
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4218
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: