Healthcare Provider Details

I. General information

NPI: 1649257569
Provider Name (Legal Business Name): DAVID H JELLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 10/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 E 41ST ST 1ST FLOOR, STE B
TULSA OK
74135-2527
US

IV. Provider business mailing address

PO BOX 268838
OKLAHOMA CITY OK
73126-8838
US

V. Phone/Fax

Practice location:
  • Phone: 918-619-4800
  • Fax: 918-619-4801
Mailing address:
  • Phone: 918-619-4800
  • Fax: 918-619-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number16192
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16192
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number16192
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: