1639170277 NPI number — MR. GARY WESLEY BLAIR D.PH.

Table of content: MR. GARY WESLEY BLAIR D.PH. (NPI 1639170277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639170277 NPI number — MR. GARY WESLEY BLAIR D.PH.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAIR
Provider First Name:
GARY
Provider Middle Name:
WESLEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
D.PH.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1639170277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3401 WESTWOOD CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROWLETT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75088-5729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-412-1665
Provider Business Mailing Address Fax Number:
972-412-1699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 YOUNG ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75202-5433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-767-4438
Provider Business Practice Location Address Fax Number:
214-767-0323
Provider Enumeration Date:
08/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  9496 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: 43017 , 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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