Provider Demographics
NPI:1942411087
Name:GEORGE J BLAKE MD PC
Entity Type:Organization
Organization Name:GEORGE J BLAKE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-828-0230
Mailing Address - Street 1:5153 E 51ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-7456
Mailing Address - Country:US
Mailing Address - Phone:918-828-0230
Mailing Address - Fax:918-828-0231
Practice Address - Street 1:5153 E 51ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-7456
Practice Address - Country:US
Practice Address - Phone:918-828-0230
Practice Address - Fax:918-828-0231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK182452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty