Provider Demographics
NPI:1932293974
Name:CHESNUT, SHIRLEY (DO)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:CHESNUT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S. TREATY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-5330
Mailing Address - Country:US
Mailing Address - Phone:918-542-6644
Mailing Address - Fax:918-542-6167
Practice Address - Street 1:10 S. TREATY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-5330
Practice Address - Country:US
Practice Address - Phone:918-542-6644
Practice Address - Fax:918-542-6167
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK74344A010OtherCHAMPUS
OK100111160AMedicaid
OK74354A003OtherCHAMPUS
OK74344A010OtherCHAMPUS