Provider Demographics
NPI:1417036641
Name:BLAKE, GEORGE JACOB (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:JACOB
Last Name:BLAKE
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 1:5153 E 51ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-7456
Mailing Address - Country:US
Mailing Address - Phone:918-828-0230
Mailing Address - Fax:918-828-0231
Practice Address - Street 1:5153 E 51ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-7456
Practice Address - Country:US
Practice Address - Phone:918-828-0230
Practice Address - Fax:918-828-0231
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK182452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F63775Medicare UPIN