Provider Demographics
NPI:1174566772
Name:NORTHCUTT, JEFF E (MD)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:E
Last Name:NORTHCUTT
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 1:1908 N 14TH ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2014
Mailing Address - Country:US
Mailing Address - Phone:580-762-8045
Mailing Address - Fax:580-762-2798
Practice Address - Street 1:1908 N 14TH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2014
Practice Address - Country:US
Practice Address - Phone:580-762-8045
Practice Address - Fax:580-762-2798
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22394174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100120210AMedicaid
OKI41249Medicare UPIN
OK243527000Medicare ID - Type Unspecified