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:
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?:Yes
Enumeration Date:2006-07-13
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
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