Healthcare Provider Details

I. General information

NPI: 1720071616
Provider Name (Legal Business Name): JERRY WAYNE FREED D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7512 E 91ST ST
TULSA OK
74133-6050
US

IV. Provider business mailing address

7512 E 91ST ST
TULSA OK
74133-6050
US

V. Phone/Fax

Practice location:
  • Phone: 918-728-2000
  • Fax: 918-728-2001
Mailing address:
  • Phone: 918-728-2505
  • Fax: 918-728-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3853
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: