Provider Demographics
NPI:1326269648
Name:OAK, JACK ROH (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ROH
Last Name:OAK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:MSC 8109-05-04
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-991-4644
Mailing Address - Fax:314-991-4910
Practice Address - Street 1:12266 DE PAUL DR STE 305
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2514
Practice Address - Country:US
Practice Address - Phone:314-770-0991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20030091972086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209363209Medicaid
SCSCN984OtherMEDICARE
SC883253Medicaid