MEDICARE: JON W BLASCHKE MD PC

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	261Q00000X	Clinic/Center	11711	OK

General Provider Information

NPI Number	:	1679717276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JON W BLASCHKE MD PC

Provider Business Mailing Address
First Line	:	608 NW 9TH ST
Second Line	:	SUITE 4204
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73102-1049
Country	:	US
Telephone Number	:	405-232-3095
Fax Number	:	405-232-3094

Provider Business Practice Location Address
First Line	:	608 NW 9TH ST
Second Line	:	SUITE 4204
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73102-1049
Country	:	US
Telephone Number	:	405-232-3095
Fax Number	:	405-232-3094

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JON WORD BLASCHKE
Credential	:	M.D.
Telephone Number	:	405-232-3095

Provider Enumeration Date	:	04/27/2009
Last Update Date	:	06/08/2009

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