Provider Demographics
NPI:1336615046
Name:BURTIN, JERA D
Entity Type:Individual
Prefix:
First Name:JERA
Middle Name:D
Last Name:BURTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N MORELAND AVE
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-4038
Mailing Address - Country:US
Mailing Address - Phone:405-822-6847
Mailing Address - Fax:580-623-5776
Practice Address - Street 1:220 N MORELAND AVE
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-4038
Practice Address - Country:US
Practice Address - Phone:405-822-6847
Practice Address - Fax:580-623-5776
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor