Provider Demographics
NPI:1629055660
Name:JESIOLOWSKI, KEITH A (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:JESIOLOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:STE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3310
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:918-488-6010
Practice Address - Street 1:8414 E 101ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6919
Practice Address - Country:US
Practice Address - Phone:918-396-3200
Practice Address - Fax:918-369-3209
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2008-02-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK14552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE16938Medicare UPIN