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General NPI Number Information
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NPI Number | 1093711053
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Entity Type | Individual
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Provider Name | JAYSON D AVENMARG MD
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Gender | Male
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Dates
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Enumeration Date | 06/23/2005
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Last Update Date | 03/16/2010
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Provider Practice Location Address
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Address Line | 104 WALL STREET
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City | POTEAU
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State | OK
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Zip | 74953
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Country | US
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Telephone | 918-647-8635
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Fax | 918-635-3191
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Provider Business Mailing Address
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Address Line | PO BOX 689
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City | POTEAU
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State | OK
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Zip | 74953
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Country | US
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Telephone | 918-647-8635
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Fax | 918-635-3191
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | A65237
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 27369
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License Number State | OK
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