Provider Demographics
NPI:1205956851
Name:BLYTHE, SAMPSON J III (DC)
Entity type:Individual
Prefix:
First Name:SAMPSON
Middle Name:J
Last Name:BLYTHE
Suffix:III
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 1:312 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020
Mailing Address - Country:US
Mailing Address - Phone:918-358-3376
Mailing Address - Fax:918-358-3376
Practice Address - Street 1:312 S BROADWAY
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020
Practice Address - Country:US
Practice Address - Phone:918-358-3376
Practice Address - Fax:918-358-3376
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2247111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100829970AMedicaid
OK731237629001OtherBLUE CROSS BLUE SHIELD
T75343Medicare UPIN
OK100829970AMedicaid