Provider Demographics
NPI:1093994352
Name:DR. JERRY A. NELMS D.O.
Entity Type:Organization
Organization Name:DR. JERRY A. NELMS D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:
Authorized Official - Last Name:COINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-486-5564
Mailing Address - Street 1:607 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-5000
Mailing Address - Country:US
Mailing Address - Phone:918-486-5564
Mailing Address - Fax:918-486-3284
Practice Address - Street 1:607 S BROADWAY
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-5000
Practice Address - Country:US
Practice Address - Phone:918-486-5564
Practice Address - Fax:918-486-3284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1403207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty