Provider Demographics
NPI:1982608873
Name:MARSHALL, JACK E (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:E
Last Name:MARSHALL
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:PO BOX 269031
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9031
Mailing Address - Country:US
Mailing Address - Phone:405-286-9820
Mailing Address - Fax:405-286-9813
Practice Address - Street 1:14100 PARKWAY COMMONS DR STE 102
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6036
Practice Address - Country:US
Practice Address - Phone:406-286-9820
Practice Address - Fax:405-286-9813
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15252207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK050058014OtherOLD MEDICARE RR
OK100124480AMedicaid
OKP00445607OtherMEDICARE RR
OK$$$$$$$$$001OtherBC/BS
OKP00445607OtherMEDICARE RR
OK050058014OtherOLD MEDICARE RR
OK100124480AMedicaid
OK244419609Medicare PIN