Provider Demographics
NPI:1154475887
Name:JEFF E NORTHCUTT MD PLLC
Entity Type:Organization
Organization Name:JEFF E NORTHCUTT MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:E
Authorized Official - Last Name:NORTHCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-762-8045
Mailing Address - Street 1:1908 N 14TH ST STE 206
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2039
Mailing Address - Country:US
Mailing Address - Phone:580-762-8045
Mailing Address - Fax:580-762-2798
Practice Address - Street 1:1908 N 14TH ST STE 206
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2039
Practice Address - Country:US
Practice Address - Phone:580-762-8045
Practice Address - Fax:580-762-2798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22394174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200058550AMedicaid
OK200058550AMedicaid