Provider Demographics
NPI:1265829485
Name:HOSTETLER, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HOSTETLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 450130
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-0130
Mailing Address - Country:US
Mailing Address - Phone:918-877-1211
Mailing Address - Fax:918-877-1216
Practice Address - Street 1:4602 US HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-4229
Practice Address - Country:US
Practice Address - Phone:918-877-1211
Practice Address - Fax:918-877-1216
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-26
Last Update Date:2022-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK31475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200659910BMedicaid