Healthcare Provider Details

I. General information

NPI: 1073576591
Provider Name (Legal Business Name): JON JASON O'PRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 08/10/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WILFORD HALL AMBULATORY SURGICAL CENTER 1100 WILFORD HALL LOOP, BLDG 4554
JBSA-LACKLAND AFB TX
78236-9908
US

IV. Provider business mailing address

RAF LAKENHEATH 48 MDG/SGOT UNIT 5210 BOX 230
APO AE
09461-0230
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-6376
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberL7505
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: