Provider Demographics
NPI:1386688778
Name:LITTLE, BLAKE A (MD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:A
Last Name:LITTLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 S UTICA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4013
Mailing Address - Country:US
Mailing Address - Phone:918-579-3826
Mailing Address - Fax:918-579-1262
Practice Address - Street 1:1120 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4012
Practice Address - Country:US
Practice Address - Phone:918-579-1000
Practice Address - Fax:918-579-1218
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16264207RC0200X, 174400000X
MN1170174400000X
KS04-25029174400000X
IL036-106221174400000X
ARN-8113174400000X
MOR4J98174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206894506Medicaid
KS0000205533OtherKS BLUE CROSS
KS100156240HMedicaid
AR121409001Medicaid
AR55425OtherAR BLUE CROSS
OK100178780AMedicaid
KS2050549604Medicaid
KS0000205533OtherKS BLUE CROSS
KS100156240HMedicaid
AR110230357Medicare ID - Type UnspecifiedRAILROAD MEDICARE
AR55425Medicare ID - Type UnspecifiedARKANSAS MEDICARE
AR121409001Medicaid
AR55425OtherAR BLUE CROSS
MO000013552Medicare ID - Type UnspecifiedPROVIDER NUMBER
IL201284Medicare ID - Type Unspecified