Provider Demographics
NPI:1538364245
Name:BLISS, THERON JOSEPH (DO)
Entity type:Individual
Prefix:
First Name:THERON
Middle Name:JOSEPH
Last Name:BLISS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3701
Mailing Address - Country:US
Mailing Address - Phone:918-403-7144
Mailing Address - Fax:918-856-5561
Practice Address - Street 1:220 S ELM ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037
Practice Address - Country:US
Practice Address - Phone:918-403-7144
Practice Address - Fax:918-856-5561
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4618207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine