Healthcare Provider Details

I. General information

NPI: 1790199982
Provider Name (Legal Business Name): JOHN BELK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 W CHEROKEE ST
WAGONER OK
74467-4621
US

IV. Provider business mailing address

1103 W CHEROKEE
WAGONER OK
74467
US

V. Phone/Fax

Practice location:
  • Phone: 918-485-3182
  • Fax:
Mailing address:
  • Phone: 918-485-3182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30768
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: