Healthcare Provider Details

I. General information

NPI: 1982608873
Provider Name (Legal Business Name): JACK E MARSHALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14100 PARKWAY COMMONS DR STE 102
OKLAHOMA CITY OK
73134-6036
US

IV. Provider business mailing address

PO BOX 269031
OKLAHOMA CITY OK
73126-9031
US

V. Phone/Fax

Practice location:
  • Phone: 406-286-9820
  • Fax: 405-286-9813
Mailing address:
  • Phone: 405-286-9820
  • Fax: 405-286-9813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number15252
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number15252
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: