Basic Information
| Provider Information | |||||||||
| NPI: | 1053377002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANHOOSER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | ROSS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 N INDEPENDENCE AVE | ||||||||
| Address2: | 280 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802332300 | ||||||||
| FaxNumber: | 5805481497 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S MONROE ST | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737017211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802332300 | ||||||||
| FaxNumber: | 5805481497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 04/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 16487 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00328377 | 01 | OK | RR MEDICARE | OTHER | 100125450A | 05 | OK | MEDICAID |