Provider Demographics
NPI:1578003992
Name:FENNEMA, GARY (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:FENNEMA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 W 112TH PL S
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2127
Mailing Address - Country:US
Mailing Address - Phone:918-691-4601
Mailing Address - Fax:
Practice Address - Street 1:744 W 9TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9020
Practice Address - Country:US
Practice Address - Phone:918-599-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-04
Last Update Date:2022-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6402207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine