Provider Demographics
NPI:1447385091
Name:O'STASIK, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:O'STASIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:BUTCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1245 S UTICA AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4214
Mailing Address - Country:US
Mailing Address - Phone:918-579-3850
Mailing Address - Fax:918-579-3859
Practice Address - Street 1:1245 S UTICA AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4214
Practice Address - Country:US
Practice Address - Phone:918-579-3850
Practice Address - Fax:918-579-3859
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24940207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200525560AMedicaid
OK200525560AMedicaid