Basic Information
| Provider Information | |||||||||
| NPI: | 1922328772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACIAS | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 N FLORENCE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740173189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183411886 | ||||||||
| FaxNumber: | 9183431727 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 N FLORENCE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740173189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183411886 | ||||||||
| FaxNumber: | 9183431727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2010 | ||||||||
| LastUpdateDate: | 02/22/2016 | ||||||||
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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 | 207R00000X | 5044 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200493630A | 05 | OK | MEDICAID |