Provider Demographics
NPI:1578544086
Name:CRAIN, JERRY C (DO)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:C
Last Name:CRAIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1205 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-3114
Mailing Address - Country:US
Mailing Address - Phone:918-371-5885
Mailing Address - Fax:918-371-0584
Practice Address - Street 1:1205 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-3114
Practice Address - Country:US
Practice Address - Phone:918-371-5885
Practice Address - Fax:918-371-0584
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200305570AMedicaid
OK080114764OtherPALMETTO GBA-RAILROAD
OK731479816001OtherBLUE CROSS BLUE SHIELD
OK731479816OtherTRICARE
OK731479816001OtherBLUE CROSS BLUE SHIELD
OK200305570AMedicaid