Healthcare Provider Details

I. General information

NPI: 1316905433
Provider Name (Legal Business Name): DAVID G BLACKSHAW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 05/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 N PORTLAND AVE
OKLAHOMA CITY OK
73112-2074
US

IV. Provider business mailing address

5609 NW 133RD TER
OKLAHOMA CITY OK
73142-4449
US

V. Phone/Fax

Practice location:
  • Phone: 405-604-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number16528
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number16528
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: