Provider Demographics
NPI:1134325608
Name:MOAD, JEREMY BRANDON (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:BRANDON
Last Name:MOAD
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 1:105 S BRYANT AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6361
Mailing Address - Country:US
Mailing Address - Phone:405-715-2022
Mailing Address - Fax:405-715-2905
Practice Address - Street 1:105 S BRYANT AVE STE 104
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034
Practice Address - Country:US
Practice Address - Phone:405-715-2022
Practice Address - Fax:405-715-2905
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25707207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine