Provider Demographics
NPI:1508803156
Name:KERLEY, JIMMY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:MICHAEL
Last Name:KERLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:MICHAEL
Other - Last Name:KERLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6130
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73506
Mailing Address - Country:US
Mailing Address - Phone:580-536-2121
Mailing Address - Fax:580-536-2150
Practice Address - Street 1:104 NW 31ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-536-2121
Practice Address - Fax:580-536-2150
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG35152085R0001X, 207RH0003X, 207R00000X
OK305312085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138876102Medicaid
TX138876106Medicaid
TX13876404Medicaid
TX138876112Medicaid
TX8R1484OtherBLUE CROSS OF TX
TX138876101Medicaid
TX138876105Medicaid
TX138876108Medicaid
OK100101320AMedicaid
TX138876111Medicaid
TX13876404Medicaid
TX88R081Medicare PIN
E45878Medicare UPIN
TX138876105Medicaid
TX138876106Medicaid