Basic Information
| Provider Information | |||||||||
| NPI: | 1932293974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHESNUT | ||||||||
| FirstName: | SHIRLEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10 S. TREATY | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743545330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185426644 | ||||||||
| FaxNumber: | 9185426167 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 S. TREATY | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743545330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185426644 | ||||||||
| FaxNumber: | 9185426167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 06/16/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2107 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 74344A010 | 01 | OK | CHAMPUS | OTHER | 100111160A | 05 | OK | MEDICAID | 74354A003 | 01 | OK | CHAMPUS | OTHER |