Healthcare Provider Details

I. General information

NPI: 1275580268
Provider Name (Legal Business Name): JON WORD BLASCHKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 NW 9TH ST SUITE 4204
OKLAHOMA CITY OK
73102-1049
US

IV. Provider business mailing address

608 NW 9TH ST SUITE 4204
OKLAHOMA CITY OK
73102-1049
US

V. Phone/Fax

Practice location:
  • Phone: 405-232-3095
  • Fax: 405-232-3094
Mailing address:
  • Phone: 405-232-3095
  • Fax: 405-232-3094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number11711
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: