Provider Demographics
NPI:1669478962
Name:WEST, JERRY DEAN (OD)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:DEAN
Last Name:WEST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7171 S YALE AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6367
Mailing Address - Country:US
Mailing Address - Phone:918-492-1722
Mailing Address - Fax:918-492-3578
Practice Address - Street 1:7171 S YALE AVE
Practice Address - Street 2:STE 104
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6367
Practice Address - Country:US
Practice Address - Phone:918-492-1722
Practice Address - Fax:918-492-3578
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK0853152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4486602OtherAETNA
OK100764250AMedicaid
4486602OtherAETNA