Provider Demographics
NPI:1235395542
Name:BUSH, BLAKE ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:ROBERT
Last Name:BUSH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:908 N ROCKFORD RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2540
Mailing Address - Country:US
Mailing Address - Phone:580-223-7333
Mailing Address - Fax:580-319-4411
Practice Address - Street 1:908 N ROCKFORD RD
Practice Address - Street 2:SUITE E
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2540
Practice Address - Country:US
Practice Address - Phone:580-223-7333
Practice Address - Fax:580-319-4411
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2550152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200205700AMedicaid