Provider Demographics
NPI:1003040262
Name:O'BANION, JACQUELYN A (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:A
Last Name:O'BANION
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365B CLIFTON RD NE
Mailing Address - Street 2:EMORY CLINIC BUILDING B
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1013
Mailing Address - Country:US
Mailing Address - Phone:404-778-2020
Mailing Address - Fax:
Practice Address - Street 1:608 STANTON L YOUNG BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5014
Practice Address - Country:US
Practice Address - Phone:405-271-6060
Practice Address - Fax:405-271-1926
Is Sole Proprietor?:No
Enumeration Date:2009-05-03
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK27920207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200306430BMedicaid
OK200306430BMedicaid