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: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S ELM ST
JENKS OK
74037
US

IV. Provider business mailing address

220 S ELM ST
JENKS OK
74037-3701
US

V. Phone/Fax

Practice location:
  • Phone: 918-403-7144
  • Fax: 918-856-5561
Mailing address:
  • Phone: 918-403-7144
  • Fax: 918-856-5561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4618
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4618
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: