Provider Demographics
NPI:1871561696
Name:HILL, JAN RUSSELL (MD)
Entity type:Individual
Prefix:DR
First Name:JAN
Middle Name:RUSSELL
Last Name:HILL
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 1:1715 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2763
Mailing Address - Country:US
Mailing Address - Phone:580-762-9292
Mailing Address - Fax:580-762-1660
Practice Address - Street 1:1715 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2763
Practice Address - Country:US
Practice Address - Phone:580-762-9292
Practice Address - Fax:580-762-1660
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5350485OtherAETNA
OKD16490Medicare UPIN
OK$$$$$$$$$TMedicare PIN