Provider Demographics
NPI:1306896998
Name:BLESCH, LAURI SUE (MD)
Entity type:Individual
Prefix:DR
First Name:LAURI
Middle Name:SUE
Last Name:BLESCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:SUE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10512 N 110TH EAST AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-6636
Mailing Address - Country:US
Mailing Address - Phone:918-376-8901
Mailing Address - Fax:918-376-8929
Practice Address - Street 1:10512 N 110TH EAST AVE
Practice Address - Street 2:STE 240
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-6636
Practice Address - Country:US
Practice Address - Phone:918-376-8901
Practice Address - Fax:918-376-8929
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17769208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100122190CMedicaid
E87144Medicare UPIN
248426602Medicare ID - Type Unspecified