Provider Demographics
NPI:1255537304
Name:FULLINGIM, JEREMY SCOTT (DO)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
Last Name:FULLINGIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12029 S 14TH CT
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-4954
Mailing Address - Country:US
Mailing Address - Phone:918-269-3359
Mailing Address - Fax:
Practice Address - Street 1:4500 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5229
Practice Address - Country:US
Practice Address - Phone:918-599-5031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK41862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology