Provider Demographics
NPI:1093755266
Name:VILAR-JENSEN, HETLEVIA R (MD)
Entity Type:Individual
Prefix:
First Name:HETLEVIA
Middle Name:R
Last Name:VILAR-JENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HETLEVIA
Other - Middle Name:R
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 11457
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4005
Mailing Address - Country:US
Mailing Address - Phone:405-733-0313
Mailing Address - Fax:405-733-0140
Practice Address - Street 1:109 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WETUMKA
Practice Address - State:OK
Practice Address - Zip Code:74883-4015
Practice Address - Country:US
Practice Address - Phone:405-452-5400
Practice Address - Fax:405-452-3000
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200031400BOtherSOONERCARE-INDIVIDUAL
OK200031400AMedicaid
OK200031400AMedicaid
OK249422202Medicare ID - Type UnspecifiedINDIVIDUAL