Healthcare Provider Details

I. General information

NPI: 1033106448
Provider Name (Legal Business Name): ROBERT V BLAKEBURN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 08/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FRISCO AVE
CLINTON OK
73601-3306
US

IV. Provider business mailing address

800 FRISCO AVE
CLINTON OK
73601-3306
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-2700
  • Fax: 580-323-2718
Mailing address:
  • Phone: 580-323-2700
  • Fax: 580-323-2718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17199
License Number StateOK

VIII. Authorized Official

Name: ROBERT VAN BLAKEBURN
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 580-323-2700