Healthcare Provider Details

I. General information

NPI: 1619670510
Provider Name (Legal Business Name): BLAKE EDWARD KOSTAL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 S YALE AVE
TULSA OK
74136-1902
US

IV. Provider business mailing address

6600 S YALE AVE STE 1200
TULSA OK
74136-3333
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-2200
  • Fax:
Mailing address:
  • Phone: 918-499-4855
  • Fax: 918-488-6098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number8570
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: