Healthcare Provider Details

I. General information

NPI: 1730554031
Provider Name (Legal Business Name): JAY L KROTTINGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 11/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S LEWIS AVE
TULSA OK
74104-1615
US

IV. Provider business mailing address

PO BOX 1430 LOCKBOX #5120
JENKS OK
74037-1430
US

V. Phone/Fax

Practice location:
  • Phone: 918-770-9333
  • Fax: 918-213-4888
Mailing address:
  • Phone: 918-770-9333
  • Fax: 918-213-4888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: