Individual
JERRY DAVID WHATLEY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
509 GRAND AVE, ARDMORE, OK 73401-4338
(580) 223-3300
(580) 223-3320
Mailing address
936 DEESE RD, ARDMORE, OK 73401-9315
(580) 224-9035
Taxonomy
Speciality
Code
Description
License number
State
207QA0000X
Adolescent Medicine (Family Medicine) Physician
Primary
19096
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100114070A
—
OK
01
—
100114070G
SOONERCARE MCD #
OK
01
—
19096
OKLAHOMA LICENSE #
OK
01
—
731612230
TAX ID #
OK
Enumeration date
05/11/2006
Last updated
01/07/2011
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