Provider Demographics
NPI:1548200751
Name:PETRAY, JACQUELINE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PETRAY
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 1:6600 S YALE AVE STE 1400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3331
Mailing Address - Country:US
Mailing Address - Phone:888-247-0125
Mailing Address - Fax:918-832-6055
Practice Address - Street 1:6565 S YALE AVE STE 312
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8304
Practice Address - Country:US
Practice Address - Phone:918-502-7050
Practice Address - Fax:918-502-7055
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1000074870AMedicaid
OK244529110Medicare PIN
OK1000074870AMedicaid