Provider Demographics
NPI:1487970158
Name:GILMORE, JESICAH MARIE (MD)
Entity type:Individual
Prefix:
First Name:JESICAH
Middle Name:MARIE
Last Name:GILMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:550 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-3820
Mailing Address - Country:US
Mailing Address - Phone:918-588-1900
Mailing Address - Fax:918-582-6405
Practice Address - Street 1:550 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-3820
Practice Address - Country:US
Practice Address - Phone:918-588-1900
Practice Address - Fax:918-582-6405
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2015-06-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK27867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100732910-GOtherGROUP MEDICAID/SOONERCARE
OK200330420 BMedicaid
OK73-1042545OtherGROUP BCBS
OK731042545001OtherGROUP TRICARE
OK100732910-AOtherGROUP MEDICAID/SOONERCARE
OK73-1042545OtherGROUP COMMUNITY CARE OF OKLAHOMA
OK73-1042545OtherGROUP MEDICARE