Provider Demographics
NPI:1558312173
Name:EXON, WALTER JAY (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:JAY
Last Name:EXON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 S UTICA AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4000
Mailing Address - Country:US
Mailing Address - Phone:918-579-3825
Mailing Address - Fax:918-579-1262
Practice Address - Street 1:1245 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4214
Practice Address - Country:US
Practice Address - Phone:918-560-3832
Practice Address - Fax:918-583-0423
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10770208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100094000AMedicaid
C94911Medicare UPIN
OK100094000AMedicaid