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NPI Code Detail

MEDICARE: DENNIS SIDNEY BLACKSTAD DO

MEDICARE: DENNIS SIDNEY BLACKSTAD DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207P00000XEmergency Medicine Physician3650OK
2207Q00000XFamily Medicine Physician3650OK

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1710040894
Entity Type Code : Individual
Provider Name (Legal Business Name) : DENNIS SIDNEY BLACKSTAD DO
Provider Business Mailing Address
First Line : 730 E TAFT AVE
Second Line :
City : SAPULPA
State : OK
Zip : 74066-5766
Country : US
Telephone Number : 918-216-4006
Fax Number : 918-216-4007
Provider Business Practice Location Address
First Line : 730 E TAFT AVE
Second Line :
City : SAPULPA
State : OK
Zip : 74066-5766
Country : US
Telephone Number : 918-216-4006
Fax Number : 918-216-4007
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/19/2006
Last Update Date : 01/20/2016

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Directions to “ DENNIS SIDNEY BLACKSTAD DO” Practice Location

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