Provider Demographics
NPI:1821175076
Name:BLANTON, TIMOTHY R (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:R
Last Name:BLANTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-4302
Mailing Address - Country:US
Mailing Address - Phone:580-765-2482
Mailing Address - Fax:580-765-4852
Practice Address - Street 1:101 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4302
Practice Address - Country:US
Practice Address - Phone:580-765-2482
Practice Address - Fax:580-765-4852
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3102111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00288810OtherRAILROAD MEDICARE
OKP00288810OtherRAILROAD MEDICARE