Provider Demographics
NPI:1689679813
Name:LEEMASTER, JAY E (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:E
Last Name:LEEMASTER
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 1:2909 S TELEPHONE RD
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2937
Mailing Address - Country:US
Mailing Address - Phone:405-799-7510
Mailing Address - Fax:405-799-4742
Practice Address - Street 1:2909 S TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2937
Practice Address - Country:US
Practice Address - Phone:405-799-7510
Practice Address - Fax:405-799-4742
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13242174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731434343001OtherBXBS
OK100123420AMedicaid
OK731434343OtherTAX ID#
OK731434343001OtherBXBS