Basic Information
| Provider Information | |||||||||
| NPI: | 1568703700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIDDLETON | ||||||||
| FirstName: | BLAKE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9600 BROADWAY EXT | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731147408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052309000 | ||||||||
| FaxNumber: | 4052309175 | ||||||||
| Practice Location | |||||||||
| Address1: | 9600 BROADWAY EXT | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052309000 | ||||||||
| FaxNumber: | 4052309175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | Q8566 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | 5599 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.