Basic Information
| Provider Information | |||||||||
| NPI: | 1558308726 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENNINGS | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 849 | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748020849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052735801 | ||||||||
| FaxNumber: | 4058783814 | ||||||||
| Practice Location | |||||||||
| Address1: | 3315 KETHLEY RD | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748049638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052735801 | ||||||||
| FaxNumber: | 4058783814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 08/30/2012 | ||||||||
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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 | 207V00000X | 22425 | OK | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 200051470A | 05 | OK | MEDICAID |