Healthcare Provider Details

I. General information

NPI: 1912859547
Provider Name (Legal Business Name): BLAKE LOUIS ATWOOD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2026
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 N 6TH ST
JENKS OK
74037-4101
US

IV. Provider business mailing address

224 N 6TH ST
JENKS OK
74037-4101
US

V. Phone/Fax

Practice location:
  • Phone: 918-810-8233
  • Fax:
Mailing address:
  • Phone: 918-810-8233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0205X
TaxonomyPh.D. Medical Genetics Physician
License Number2019027
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: