Provider Demographics
NPI:1033106448
Name:ROBERT V BLAKEBURN MD PC
Entity Type:Organization
Organization Name:ROBERT V BLAKEBURN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:BLAKEBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-323-2700
Mailing Address - Street 1:800 FRISCO AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-3306
Mailing Address - Country:US
Mailing Address - Phone:580-323-2700
Mailing Address - Fax:580-323-2718
Practice Address - Street 1:800 FRISCO AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-3306
Practice Address - Country:US
Practice Address - Phone:580-323-2700
Practice Address - Fax:580-323-2718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17199207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100110960CMedicaid
OK100110960CMedicaid
DF6022Medicare PIN
F20172Medicare UPIN
OK=========001OtherBCBS OF OK