Basic Information
| Provider Information | |||||||||
| NPI: | 1255537304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLINGIM | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12029 S 14TH CT | ||||||||
| Address2: | |||||||||
| City: | JENKS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740374954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182693359 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4500 S GARNETT RD | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741465229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185995031 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 06/13/2012 | ||||||||
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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 | 4186 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.