Provider Demographics
NPI:1619934221
Name:JACOBS, LUSTER I (MD)
Entity Type:Individual
Prefix:
First Name:LUSTER
Middle Name:I
Last Name:JACOBS
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:PO BOX 22063
Mailing Address - Street 2:DEPT 0491
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-2063
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:ER DEPT
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-494-6528
Practice Address - Fax:405-749-4561
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK12716207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100108940CMedicaid
OKD88937Medicare UPIN
OK248425705Medicare PIN
OK080156012Medicare PIN
OK930001284Medicare PIN
OK24H620509Medicare PIN