Healthcare Provider Details

I. General information

NPI: 1700878378
Provider Name (Legal Business Name): JACK STEPHEN ALDRIDGE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30011 E STATE HIGHWAY 51
COWETA OK
74429-7681
US

IV. Provider business mailing address

6600 S YALE AVE SUITE 1400
TULSA OK
74136-3347
US

V. Phone/Fax

Practice location:
  • Phone: 918-486-2161
  • Fax: 918-486-3135
Mailing address:
  • Phone: 918-488-6001
  • Fax: 918-488-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOK2679
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: