Provider Demographics
NPI:1093754251
Name:BLALOCK, JAMES MATTISON (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MATTISON
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 269086
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126
Mailing Address - Country:US
Mailing Address - Phone:405-231-3857
Mailing Address - Fax:405-272-7977
Practice Address - Street 1:608 NW 9TH ST
Practice Address - Street 2:SUITE 6110
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-1049
Practice Address - Country:US
Practice Address - Phone:405-272-6909
Practice Address - Fax:405-231-3723
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK12285207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100071500BMedicaid
OKP00332846OtherINDIVIDUAL RAILROAD MCARE
OKD34410Medicare UPIN
OK100071500BMedicaid