Provider Demographics
NPI:1710040894
Name:BLACKSTAD, DENNIS SIDNEY (DO)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:SIDNEY
Last Name:BLACKSTAD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 E TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-5766
Mailing Address - Country:US
Mailing Address - Phone:918-216-4006
Mailing Address - Fax:918-216-4007
Practice Address - Street 1:730 E TAFT AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-5766
Practice Address - Country:US
Practice Address - Phone:918-216-4006
Practice Address - Fax:918-216-4007
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3650207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100171140AMedicaid
H04409Medicare UPIN
400522419Medicare ID - Type Unspecified