Basic Information
| Provider Information | |||||||||
| NPI: | 1033648951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEST | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | BRYON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1923 S UTICA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741046520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187487585 | ||||||||
| FaxNumber: | 9184036352 | ||||||||
| Practice Location | |||||||||
| Address1: | 1923 S UTICA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741046520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187487585 | ||||||||
| FaxNumber: | 9184036352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2017 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 33989 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.