Provider Demographics
NPI:1902120934
Name:SAMUEL, JESSE E
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:E
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 E MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73131-1253
Mailing Address - Country:US
Mailing Address - Phone:405-310-8591
Mailing Address - Fax:405-330-1811
Practice Address - Street 1:1919 E MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73131-1253
Practice Address - Country:US
Practice Address - Phone:405-310-8591
Practice Address - Fax:405-330-1811
Is Sole Proprietor?:No
Enumeration Date:2010-03-19
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine