Healthcare Provider Details

I. General information

NPI: 1821162512
Provider Name (Legal Business Name): MELANIE R. BLACKSTOCK, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6465 S YALE AVE SUITE 310
TULSA OK
74136-7823
US

IV. Provider business mailing address

6465 S YALE AVE SUITE 310
TULSA OK
74136-7823
US

V. Phone/Fax

Practice location:
  • Phone: 918-236-3000
  • Fax: 918-236-3060
Mailing address:
  • Phone: 918-236-3000
  • Fax: 918-236-3060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number17647
License Number StateOK

VIII. Authorized Official

Name: SARAH DOERPINGHAUS
Title or Position: OFFICE MANAGER
Credential: CREDENTIALING
Phone: 918-236-3000