Healthcare Provider Details

I. General information

NPI: 1639912595
Provider Name (Legal Business Name): JACK SUNTKEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W 17TH ST
TULSA OK
74107-1886
US

IV. Provider business mailing address

2893 W 112TH ST S
JENKS OK
74037
US

V. Phone/Fax

Practice location:
  • Phone: 918-584-4611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1639912595
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: