Provider Demographics
NPI:1861549743
Name:PACK, JASON (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 720778
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-4602
Mailing Address - Country:US
Mailing Address - Phone:405-535-7669
Mailing Address - Fax:
Practice Address - Street 1:2825 PARKLAWN DR
Practice Address - Street 2:RADIOLOGY DEPT.
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4201
Practice Address - Country:US
Practice Address - Phone:405-610-8398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK225872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology