Healthcare Provider Details

I. General information

NPI: 1093755266
Provider Name (Legal Business Name): HETLEVIA R VILAR-JENSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HETLEVIA R JENSEN MD

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 11/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S MAIN ST
WETUMKA OK
74883-4015
US

IV. Provider business mailing address

PO BOX 11457
BELFAST ME
04915-4005
US

V. Phone/Fax

Practice location:
  • Phone: 405-452-5400
  • Fax: 405-452-3000
Mailing address:
  • Phone: 405-733-0313
  • Fax: 405-733-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23895
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: