Provider Demographics
NPI:1972638773
Name:JEFFREY R SHUART MD PC
Entity Type:Organization
Organization Name:JEFFREY R SHUART MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHUART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-363-0052
Mailing Address - Street 1:115 W BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74631-2800
Mailing Address - Country:US
Mailing Address - Phone:580-363-3501
Mailing Address - Fax:580-363-3477
Practice Address - Street 1:115 W BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631-2800
Practice Address - Country:US
Practice Address - Phone:580-363-3501
Practice Address - Fax:580-363-3477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18498207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100751170AMedicaid
OKF58955Medicare UPIN
OK500522051Medicare ID - Type Unspecified