Provider Demographics
NPI:1235212630
Name:DANCER, JACK T I (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:T
Last Name:DANCER
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W 6TH AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4375
Mailing Address - Country:US
Mailing Address - Phone:405-533-1074
Mailing Address - Fax:
Practice Address - Street 1:1301 W 6TH AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4375
Practice Address - Country:US
Practice Address - Phone:405-533-1074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7845208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery