Provider Demographics
NPI:1497827372
Name:JEANNE E HEYSER EASTERLY DO
Entity type:Organization
Organization Name:JEANNE E HEYSER EASTERLY DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HEYSER EASTERLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-749-4668
Mailing Address - Street 1:PO BOX 21228
Mailing Address - Street 2:DEPT 94
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-1228
Mailing Address - Country:US
Mailing Address - Phone:918-299-8232
Mailing Address - Fax:918-299-8233
Practice Address - Street 1:800 S JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9003
Practice Address - Country:US
Practice Address - Phone:918-749-4668
Practice Address - Fax:918-749-4669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2010-02-22
Deactivation Date:2008-01-30
Deactivation Code:
Reactivation Date:2010-02-22
Provider Licenses
StateLicense IDTaxonomies
OK2417204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200014570AMedicaid
OK200014570AMedicaid
OK400522337Medicare ID - Type Unspecified