Healthcare Provider Details

I. General information

NPI: 1215908041
Provider Name (Legal Business Name): JACK ROBIN SNEDDEN III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10502 NORTH 110TH EAST AVENUE
OWASSO OK
74055-6655
US

IV. Provider business mailing address

10502 N 110TH EAST AVE
OWASSO OK
74055-6655
US

V. Phone/Fax

Practice location:
  • Phone: 918-376-8590
  • Fax: 918-376-8549
Mailing address:
  • Phone: 918-376-8590
  • Fax: 918-376-8549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21312
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number21312
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: