MEDICARE: JAMES MATTISON BLALOCK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RP1001X	Pulmonary Disease Physician	12285	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	P00332846	OTHER	OK	INDIVIDUAL RAILROAD MCARE

General Provider Information

NPI Number	:	1093754251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES MATTISON BLALOCK MD

Provider Business Mailing Address
First Line	:	PO BOX 269086
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73126
Country	:	US
Telephone Number	:	405-231-3857
Fax Number	:	405-272-7977

Provider Business Practice Location Address
First Line	:	608 NW 9TH ST
Second Line	:	SUITE 6110
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73102-1049
Country	:	US
Telephone Number	:	405-272-6909
Fax Number	:	405-231-3723

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	06/04/2015

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