Provider Demographics
NPI:1477592186
Name:BLALOCK, DEBORAH SUE (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:SUE
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10914 HEFNER POINTE DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120
Mailing Address - Country:US
Mailing Address - Phone:405-608-2772
Mailing Address - Fax:405-608-2324
Practice Address - Street 1:10914 HEFNER POINTE DR
Practice Address - Street 2:SUITE 304
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120
Practice Address - Country:US
Practice Address - Phone:405-608-2772
Practice Address - Fax:405-608-2324
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17054207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100130200AMedicaid
OK244621401Medicare PIN
OK100130200AMedicaid