Healthcare Provider Details

I. General information

NPI: 1528300811
Provider Name (Legal Business Name): JEFFREY LAWRENCE CUNNINGHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2488 E 81ST ST STE 290
TULSA OK
74137-4265
US

IV. Provider business mailing address

2488 E 81ST ST STE 290
TULSA OK
74137-4265
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-2665
  • Fax: 918-927-3201
Mailing address:
  • Phone: 918-927-3226
  • Fax: 918-927-3193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number30836
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30836
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: