Provider Demographics
NPI:1558438887
Name:MOSELEY, JACK ELLIS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ELLIS
Last Name:MOSELEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2600 E. WILLOW
Mailing Address - Street 2:NORTHERN OKLAHOMA RESOURCE CENTER
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-8715
Mailing Address - Country:US
Mailing Address - Phone:580-213-2700
Mailing Address - Fax:580-548-2647
Practice Address - Street 1:2600 E WILLOW RD
Practice Address - Street 2:NORTHERN OKLAHOMA RESOURCE CENTER
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-8715
Practice Address - Country:US
Practice Address - Phone:580-213-2700
Practice Address - Fax:580-548-2647
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK20477207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAG90142Medicare UPIN
OKG90142Medicare UPIN