Provider Demographics
NPI:1639208937
Name:ENDSLEY, JEFFREY D (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:ENDSLEY
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 1:1524 W OKMULGEE ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-6741
Mailing Address - Country:US
Mailing Address - Phone:918-682-5397
Mailing Address - Fax:
Practice Address - Street 1:1524 W OKMULGEE ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-6741
Practice Address - Country:US
Practice Address - Phone:918-682-5397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3027207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKF35608Medicare UPIN