Provider Demographics
NPI:1417999616
Name:BLAIR, GREGORY L (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:BLAIR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 268922
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8922
Mailing Address - Country:US
Mailing Address - Phone:405-231-3857
Mailing Address - Fax:405-272-7977
Practice Address - Street 1:7 S MICKEY MANTLE DR
Practice Address - Street 2:SUITE 325
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-2458
Practice Address - Country:US
Practice Address - Phone:405-232-0101
Practice Address - Fax:405-232-0102
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK19544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK700309OtherPTAN
OK100091280AMedicaid
OK100091280AMedicaid