Provider Demographics
NPI:1053522193
Name:JERRY C BOUMAN DO PC
Entity type:Organization
Organization Name:JERRY C BOUMAN DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-296-0900
Mailing Address - Street 1:PO BOX 21568
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-1568
Mailing Address - Country:US
Mailing Address - Phone:918-296-0900
Mailing Address - Fax:918-296-0985
Practice Address - Street 1:715 W MAIN ST
Practice Address - Street 2:SUITE H
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3554
Practice Address - Country:US
Practice Address - Phone:918-296-0900
Practice Address - Fax:918-296-0985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2996208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty