Provider Demographics
NPI:1730554031
Name:KROTTINGER, JAY L
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:L
Last Name:KROTTINGER
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:PO BOX 1430
Mailing Address - Street 2:LOCKBOX #5120
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-1430
Mailing Address - Country:US
Mailing Address - Phone:918-770-9333
Mailing Address - Fax:918-213-4888
Practice Address - Street 1:22 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-1615
Practice Address - Country:US
Practice Address - Phone:918-770-9333
Practice Address - Fax:918-213-4888
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier