Provider Demographics
NPI:1720192388
Name:COLE, JERRY JAY (DO)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:JAY
Last Name:COLE
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 1:1202 W CHEROKEE ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4629
Mailing Address - Country:US
Mailing Address - Phone:918-485-1393
Mailing Address - Fax:918-485-1305
Practice Address - Street 1:1200 W CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4624
Practice Address - Country:US
Practice Address - Phone:918-485-1393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3922207X00000X
MO30805207X00000X
FLOS7100207X00000X
ME845207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100109640AMedicaid
OK249320002Medicare PIN
OKE69138Medicare UPIN