Individual
JEREMY THEISEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1900 N 14TH ST, PONCA CITY, OK 74601-2035
(580) 765-0575
Mailing address
1900 N 14TH ST, PONCA CITY, OK 74601-2035
(580) 765-0575
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
29296
OK
2085R0202X
Diagnostic Radiology Physician
25IA12501900
NJ
2085R0202X
Diagnostic Radiology Physician
Primary
29296
OK
2085R0202X
Diagnostic Radiology Physician
MD-23144
HI
Other
Enumeration date
05/29/2012
Last updated
09/23/2025
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