Provider Demographics
NPI:1164419560
Name:BLAKEBURN, ROBERT VAN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:VAN
Last Name:BLAKEBURN
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 1:800 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:580-323-2276
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:580-323-2276
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17199207Q00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100110960AMedicaid
OK100110960AMedicaid
OK243521500Medicare PIN
OKF20172Medicare UPIN