Provider Demographics
NPI:1184649584
Name:MANN, MARK BLAINE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BLAINE
Last Name:MANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 N 30TH ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-3101
Mailing Address - Country:US
Mailing Address - Phone:580-323-0232
Mailing Address - Fax:580-331-1410
Practice Address - Street 1:90 N 30TH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-3101
Practice Address - Country:US
Practice Address - Phone:580-323-0232
Practice Address - Fax:580-331-1410
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK20775207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100107150CMedicaid
OK100107150DMedicaid
OK4436060740001OtherBLUE CROSS BLUE SHIELD
OK4436060740001OtherBLUE CROSS BLUE SHIELD
OK100107150CMedicaid