Provider Demographics
NPI:1356538433
Name:JACK R REID JR MD LLC
Entity type:Organization
Organization Name:JACK R REID JR MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-791-3117
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73101-0068
Mailing Address - Country:US
Mailing Address - Phone:225-791-3117
Mailing Address - Fax:225-791-3122
Practice Address - Street 1:5000 ODONAVAN BLVD STE 307
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:LA
Practice Address - Zip Code:70785-6355
Practice Address - Country:US
Practice Address - Phone:225-791-3117
Practice Address - Fax:225-791-3122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAG5769OtherBCBS
LADF0604OtherRAILROAD MCARE
LA5CF45Medicare PIN