Provider Demographics
NPI:1457691446
Name:BLANKENSHIP, JERRY B (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:B
Last Name:BLANKENSHIP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:1220 W WILLOW RD
Practice Address - Street 2:STE A
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2511
Practice Address - Country:US
Practice Address - Phone:580-234-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK7940208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology