=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417999616
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY L. BLAIR MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 02/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 S MICKEY MANTLE DR SUITE 325
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73104-2458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-232-0101
-----------------------------------------------------
Fax | 405-232-0102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 268922
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73126-8922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-231-3857
-----------------------------------------------------
Fax | 405-272-7977
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 19544
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------