Provider Demographics
NPI:1184661977
Name:CRUZAN, JEFFREY B (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:B
Last Name:CRUZAN
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 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-773-6470
Mailing Address - Fax:405-773-6463
Practice Address - Street 1:5915 W MEMORIAL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-2021
Practice Address - Country:US
Practice Address - Phone:405-773-6470
Practice Address - Fax:405-773-6463
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100258060AMedicaid
H45001Medicare UPIN
243435109Medicare ID - Type Unspecified
900522214Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER