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NPI Code Detail

MEDICARE: DR. BLAKE JUSTIN LESSELROTH MD, MBI

MEDICARE: DR. BLAKE JUSTIN LESSELROTH MD, MBI
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
1207R00000XInternal Medicine PhysicianMD24554OR
2207R00000XInternal Medicine Physician34337OK

General Provider Information

NPI Number : 1801997390
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. BLAKE JUSTIN LESSELROTH MD, MBI
Provider Business Mailing Address
First Line : 1414 E 39TH ST APT 2-349
Second Line :
City : TULSA
State : OK
Zip : 74105-3343
Country : US
Telephone Number : 971-303-3627
Fax Number :
Provider Business Practice Location Address
First Line : 4502 E 41ST ST
Second Line :
City : TULSA
State : OK
Zip : 74135-2536
Country : US
Telephone Number : 918-660-3596
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/26/2006
Last Update Date : 12/14/2018

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