Provider Demographics
NPI:1407825102
Name:JETT, ELIZABETH A (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:JETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI236
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-271-1515
Mailing Address - Fax:
Practice Address - Street 1:825 NE 10TH ST
Practice Address - Street 2:OUPB3500
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5417
Practice Address - Country:US
Practice Address - Phone:405-271-4514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK247632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
24R604421Medicare PIN