Basic Information
| Provider Information | |||||||||
| NPI: | 1497922496 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAND SPRINGS MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 EAST BROADWAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SAND SPRINGS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182463461 | ||||||||
| FaxNumber: | 9182463457 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 EAST BROADWAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SAND SPRINGS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182463461 | ||||||||
| FaxNumber: | 9182463457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2008 | ||||||||
| LastUpdateDate: | 08/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9182463461 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD, DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.