Provider Demographics
NPI:1497922496
Name:SAND SPRINGS MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:SAND SPRINGS MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:H
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD, DPM
Authorized Official - Phone:918-246-3461
Mailing Address - Street 1:401 EAST BROADWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063
Mailing Address - Country:US
Mailing Address - Phone:918-246-3461
Mailing Address - Fax:918-246-3457
Practice Address - Street 1:401 EAST BROADWAY
Practice Address - Street 2:SUITE A
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063
Practice Address - Country:US
Practice Address - Phone:918-246-3461
Practice Address - Fax:918-246-3457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK440503609CMedicare PIN