Provider Demographics
NPI:1013199157
Name:J CLARK BUNDREN, M.D., PC
Entity Type:Organization
Organization Name:J CLARK BUNDREN, M.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:BUNDREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-492-6000
Mailing Address - Street 1:5555 E 71ST ST STE 6220
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6548
Mailing Address - Country:US
Mailing Address - Phone:918-492-6000
Mailing Address - Fax:918-481-0622
Practice Address - Street 1:5555 E 71ST ST STE 6220
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6548
Practice Address - Country:US
Practice Address - Phone:918-492-6000
Practice Address - Fax:918-481-0622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13630207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty