1922148857 NPI number — BRANDON BLAKER O D P C

Table of content: (NPI 1922148857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922148857 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:
1922148857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2016
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:
78028-4252
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:
205B W WATER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-4252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-896-4044
Provider Business Practice Location Address Fax Number:
830-257-6419
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLAKER
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
830-896-2600

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)

  • Identifier: 1952441503 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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