Provider Demographics
NPI:1184121782
Name:BYERS, JACOB QUE (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:QUE
Last Name:BYERS
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 1:2100 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 MARY BAILEY
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-1832
Practice Address - Country:US
Practice Address - Phone:405-224-2100
Practice Address - Fax:405-779-2143
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK40117208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201170900AMedicaid