Provider Demographics
NPI:1134995046
Name:ELY, WILLIAM JACKSON
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JACKSON
Last Name:ELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24617 S MEADOW CIRCLE RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-3713
Mailing Address - Country:US
Mailing Address - Phone:918-933-2788
Mailing Address - Fax:
Practice Address - Street 1:7477 E 46TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-6305
Practice Address - Country:US
Practice Address - Phone:918-384-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist