Healthcare Provider Details

I. General information

NPI: 1326269648
Provider Name (Legal Business Name): JACK ROH OAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12266 DE PAUL DR STE 305
BRIDGETON MO
63044-2514
US

IV. Provider business mailing address

660 S EUCLID AVE MSC 8109-05-04
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-770-0991
  • Fax:
Mailing address:
  • Phone: 314-991-4644
  • Fax: 314-991-4910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number2003009197
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: