Basic Information
| Provider Information | |||||||||
| NPI: | 1720248529 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRONISTER | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 S HOUSTON AVE | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183825064 | ||||||||
| FaxNumber: | 9183823589 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 S HOUSTON AVE STE 304 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183825064 | ||||||||
| FaxNumber: | 9183823589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2008 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N/A | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200612050A | 05 | OK | MEDICAID |