Provider Demographics
NPI:1780634816
Name:WHATLEY, JERRY DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DAVID
Last Name:WHATLEY
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 1:936 DEESE RD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-9315
Mailing Address - Country:US
Mailing Address - Phone:580-224-9035
Mailing Address - Fax:
Practice Address - Street 1:509 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-4338
Practice Address - Country:US
Practice Address - Phone:580-223-3300
Practice Address - Fax:580-223-3320
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19096207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100114070GOtherSOONERCARE MCD #
OK19096OtherOKLAHOMA LICENSE #
OK731612230OtherTAX ID #
OK100114070AMedicaid