1396884979 NPI number — BRANDON BLAKER O D P C

Table of content: MR. JERRY CALVIN SMITH RPH (NPI 1053626895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396884979 NPI number — BRANDON BLAKER O D P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRANDON BLAKER O D P C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396884979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205B W WATER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERRVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-896-4044
Provider Business Mailing Address Fax Number:
830-257-6419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1620 AVENUE M
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONDO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78861-1756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-741-2634
Provider Business Practice Location Address Fax Number:
830-257-6419
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLAKER
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
830-741-2634

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  TX6429TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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