Basic Information
| Provider Information | |||||||||
| NPI: | 1003040262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'BANION | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1365B CLIFTON RD NE | ||||||||
| Address2: | EMORY CLINIC BUILDING B | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047782020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 608 STANTON L YOUNG BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052716060 | ||||||||
| FaxNumber: | 4052711926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2009 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207W00000X | 27920 | OK | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 200306430B | 05 | OK | MEDICAID |