1649240045 NPI number — JOHN CLARK BUNDREN MD

Table of content: JOHN CLARK BUNDREN MD (NPI 1649240045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649240045 NPI number — JOHN CLARK BUNDREN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUNDREN
Provider First Name:
JOHN
Provider Middle Name:
CLARK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649240045
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 268838
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73126-8838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-660-3632
Provider Business Mailing Address Fax Number:
918-660-3631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4444 E. 41ST ST
Provider Second Line Business Practice Location Address:
3RD FLOOR,STE B
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74135-2527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-582-0721
Provider Business Practice Location Address Fax Number:
918-582-4751
Provider Enumeration Date:
01/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  13630 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VE0102X , with the licence number: 13630 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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