Provider Demographics
NPI:1891776613
Name:BOPP, JON RONALD (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:RONALD
Last Name:BOPP
Suffix:
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 1:5780 S PEORIA AVENUE
Mailing Address - Street 2:PPAEO INC
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-7857
Mailing Address - Country:US
Mailing Address - Phone:918-858-5200
Mailing Address - Fax:918-582-4921
Practice Address - Street 1:1007 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120
Practice Address - Country:US
Practice Address - Phone:918-587-1101
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18514207V00000X
ARR4646207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A11963Medicare UPIN