Provider Demographics
NPI:1427091271
Name:DEBORAH S BLALOCK
Entity type:Organization
Organization Name:DEBORAH S BLALOCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:BLALOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-272-6909
Mailing Address - Street 1:PO BOX 60248
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73146-0248
Mailing Address - Country:US
Mailing Address - Phone:405-231-3857
Mailing Address - Fax:405-942-7743
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200079450AMedicaid
OK200079450AMedicaid