Provider Demographics
NPI:1902950165
Name:BLANKENSHIP, MATT MOREY (MD)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:MOREY
Last Name:BLANKENSHIP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0305
Mailing Address - Country:US
Mailing Address - Phone:918-481-4706
Mailing Address - Fax:918-481-4765
Practice Address - Street 1:10507 E 91ST ST
Practice Address - Street 2:270
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5589
Practice Address - Country:US
Practice Address - Phone:918-307-5480
Practice Address - Fax:918-307-5481
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22457207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200112540AMedicaid
OK200112540AMedicaid