Basic Information
| Provider Information | |||||||||
| NPI: | 1184607517 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK-WICKS | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BALL | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1515 TOWER DR STE B | ||||||||
| Address2: | |||||||||
| City: | MOORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731606181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053076668 | ||||||||
| FaxNumber: | 4057585354 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W FORREST AVE STE B | ||||||||
| Address2: | |||||||||
| City: | EUFAULA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744323205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184907011 | ||||||||
| FaxNumber: | 9184907015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4144 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200022700D | 05 | OK | MEDICAID |