Provider Demographics
NPI:1265431522
Name:NEILSON, JEFFREY C (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:NEILSON
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 1:1400 BRYAN DR
Mailing Address - Street 2:STE 300
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2158
Mailing Address - Country:US
Mailing Address - Phone:580-931-2278
Mailing Address - Fax:580-931-2274
Practice Address - Street 1:1400 BRYAN DR
Practice Address - Street 2:SUITE 304
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2156
Practice Address - Country:US
Practice Address - Phone:580-931-2278
Practice Address - Fax:580-931-2274
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8932207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1027849-01Medicaid
OK100113510AMedicaid
AR117301001Medicaid
AR117301001Medicaid
C19819Medicare UPIN