Provider Demographics
NPI:1710195003
Name:BLALOCK, TRAVIS WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:WAYNE
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 CLIFTON RD NE STE 112A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-4200
Mailing Address - Country:US
Mailing Address - Phone:404-778-3333
Mailing Address - Fax:
Practice Address - Street 1:619 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5001
Practice Address - Country:US
Practice Address - Phone:405-271-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA73100207ND0101X
CAA116875207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology