Provider Demographics
NPI:1184607517
Name:BLACK-WICKS, LAURA MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:MARIE
Last Name:BLACK-WICKS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:BALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1515 TOWER DR STE B
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6181
Mailing Address - Country:US
Mailing Address - Phone:405-307-6668
Mailing Address - Fax:405-758-5354
Practice Address - Street 1:111 W FORREST AVE STE B
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432-3205
Practice Address - Country:US
Practice Address - Phone:918-490-7011
Practice Address - Fax:918-490-7015
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200022700DMedicaid
OKOKA101961Medicare PIN
OK200022700DMedicaid
G09004Medicare UPIN