Healthcare Provider Details

I. General information

NPI: 1710195003
Provider Name (Legal Business Name): TRAVIS WAYNE BLALOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 NE 13TH ST
OKLAHOMA CITY OK
73104-5001
US

IV. Provider business mailing address

1525 CLIFTON RD NE STE 112A
ATLANTA GA
30322-4200
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-6110
  • Fax:
Mailing address:
  • Phone: 404-778-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number73100
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA116875
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: