Provider Demographics
NPI:1720248529
Name:CHRONISTER, JUSTIN DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DAVID
Last Name:CHRONISTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:717 S HOUSTON AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9006
Mailing Address - Country:US
Mailing Address - Phone:918-382-5064
Mailing Address - Fax:918-382-3589
Practice Address - Street 1:717 S HOUSTON AVE STE 304
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9023
Practice Address - Country:US
Practice Address - Phone:918-382-5064
Practice Address - Fax:918-382-3589
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-15
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDN/A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200612050AMedicaid