Provider Demographics
NPI:1114923489
Name:SHUART, JEFFREY ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROBERT
Last Name:SHUART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74631-2800
Mailing Address - Country:US
Mailing Address - Phone:580-363-3501
Mailing Address - Fax:580-363-3477
Practice Address - Street 1:115 W BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631-2800
Practice Address - Country:US
Practice Address - Phone:580-363-3501
Practice Address - Fax:580-363-3477
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18498207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100230950AMedicaid
F58955Medicare UPIN