Provider Demographics
NPI:1386633683
Name:BOYLES, GERALD D (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:D
Last Name:BOYLES
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 1:15380 S 4210 RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-0687
Mailing Address - Country:US
Mailing Address - Phone:918-343-3311
Mailing Address - Fax:
Practice Address - Street 1:10109 E 79TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4564
Practice Address - Country:US
Practice Address - Phone:918-286-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19392207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100082130AMedicaid
OKP00480572Medicare PIN
OK247701703Medicare PIN
OK249236002Medicare ID - Type Unspecified
OK100082130AMedicaid
OK1386633683Medicare PIN