Provider Demographics
NPI:1659480713
Name:BLAKE ALLEN LITTLE, M.D., L.L.C.
Entity Type:Organization
Organization Name:BLAKE ALLEN LITTLE, M.D., L.L.C.
Other - Org Name:BLAKE ALLEN LITTLE, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGMR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:QUALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-510-0129
Mailing Address - Street 1:5612 E 117TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-8528
Mailing Address - Country:US
Mailing Address - Phone:918-510-0129
Mailing Address - Fax:918-296-5172
Practice Address - Street 1:5612 E 117TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137
Practice Address - Country:US
Practice Address - Phone:918-510-0129
Practice Address - Fax:918-296-5172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4J98174400000X
ARN-8113174400000X
IL036-106221174400000X
KS04-25029174400000X
MN1170174400000X
OK16264174400000X
TN40672174400000X
GA58363174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121409001Medicaid
KS0000205533OtherKS BLUE CROSS
MO7404OtherMO BLUE CROSS
MO206894506Medicaid
AR55425OtherARKANSAS BLUE CROSS
MO150325OtherMO BLUE CROSS
OKA4877801498Medicaid
KS2050549604Medicaid
IL201283Medicare ID - Type UnspecifiedILLINOIS MEDICARE
MO150325OtherMO BLUE CROSS
KS0000205533OtherKS BLUE CROSS