Provider Demographics
NPI:1679578397
Name:GEREN, JESSE DEWAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:DEWAYNE
Last Name:GEREN
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 1:4318 W OKMULGEE ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4648
Mailing Address - Country:US
Mailing Address - Phone:918-686-0471
Mailing Address - Fax:918-686-0369
Practice Address - Street 1:4318 W OKMULGEE ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4648
Practice Address - Country:US
Practice Address - Phone:918-686-0471
Practice Address - Fax:918-686-0369
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100087920AMedicaid
OKOKAAA2146Medicare PIN
OK100087920AMedicaid
OK100087920AMedicaid