Healthcare Provider Details

I. General information

NPI: 1962499574
Provider Name (Legal Business Name): BLAKE L ANDERSON MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9001 S 101ST EAST AVE STE 280
TULSA OK
74133-5711
US

IV. Provider business mailing address

1145 S UTICA AVE STE 110
TULSA OK
74104-4013
US

V. Phone/Fax

Practice location:
  • Phone: 918-459-8824
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberL6260
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: