Provider Demographics
NPI:1205446887
Name:JACQUELYN D BOYD DO PLLC
Entity type:Organization
Organization Name:JACQUELYN D BOYD DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:DESIREE
Authorized Official - Last Name:MACINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-321-2929
Mailing Address - Street 1:311 ALAMOSA RD
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-3128
Mailing Address - Country:US
Mailing Address - Phone:405-812-2504
Mailing Address - Fax:
Practice Address - Street 1:3441 24TH AVE NW STE 105
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6716
Practice Address - Country:US
Practice Address - Phone:405-321-2929
Practice Address - Fax:405-366-8701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-07
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200929210AMedicaid