Provider Demographics
NPI:1649221177
Name:BLACKWELL, BERT ERIC (DO)
Entity Type:Individual
Prefix:DR
First Name:BERT
Middle Name:ERIC
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:
Other - Last Name:BLACKWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1145 S UTICA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4013
Mailing Address - Country:US
Mailing Address - Phone:918-579-6863
Mailing Address - Fax:918-579-6869
Practice Address - Street 1:4538 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2906
Practice Address - Country:US
Practice Address - Phone:918-712-3377
Practice Address - Fax:918-712-3373
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3343207Q00000X, 207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100188740CMedicaid
OK100188740CMedicaid