Provider Demographics
NPI:1033648951
Name:TEST, JACK BRYON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:BRYON
Last Name:TEST
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1923 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-6520
Mailing Address - Country:US
Mailing Address - Phone:918-748-7585
Mailing Address - Fax:918-403-6352
Practice Address - Street 1:1923 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-6520
Practice Address - Country:US
Practice Address - Phone:918-748-7585
Practice Address - Fax:918-403-6352
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK33989207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine