Healthcare Provider Details

I. General information

NPI: 1053248104
Provider Name (Legal Business Name): BLOOMQUIST FOOT AND ANKLE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8419 SHADOW LAKE DR
BLANCHARD OK
73010-4026
US

IV. Provider business mailing address

8419 SHADOW LAKE DR
BLANCHARD OK
73010-4026
US

V. Phone/Fax

Practice location:
  • Phone: 405-237-9106
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. MITCHELL BLOOMQUIST
Title or Position: PODIATRIST
Credential: DPM
Phone: 405-237-9106