Healthcare Provider Details

I. General information

NPI: 1538364245
Provider Name (Legal Business Name): THERON JOSEPH BLISS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W 125TH PL S
GLENPOOL OK
74033-5023
US

IV. Provider business mailing address

6600 S YALE AVE STE 1200
TULSA OK
74136-3333
US

V. Phone/Fax

Practice location:
  • Phone: 918-528-5580
  • Fax: 918-528-5576
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4618
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: