Provider Demographics
NPI:1700878378
Name:ALDRIDGE, JACK STEPHEN (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:STEPHEN
Last Name:ALDRIDGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3347
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:918-488-6010
Practice Address - Street 1:30011 E STATE HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-7681
Practice Address - Country:US
Practice Address - Phone:918-486-2161
Practice Address - Fax:918-486-3135
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK2679207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100099700AMedicaid
OK500522075OtherMEDICARE GROUP PIN
OKE07687Medicare UPIN
OK246800301Medicare PIN