Provider Demographics
NPI:1417919762
Name:CASTLEBERRY, JERRY JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:JAMES
Last Name:CASTLEBERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4012
Mailing Address - Country:US
Mailing Address - Phone:918-579-1000
Mailing Address - Fax:
Practice Address - Street 1:1120 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4012
Practice Address - Country:US
Practice Address - Phone:918-579-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8642207P00000X
ME1927207P00000X
OK4481207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8P9112OtherBLUE SHIELD
TX8D0993Medicare ID - Type Unspecified
TX8P9112OtherBLUE SHIELD