Provider Demographics
NPI:1003803172
Name:CHRISTENSEN, BLAKE R (OD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:R
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:HEWITT
Mailing Address - State:TX
Mailing Address - Zip Code:76643-0296
Mailing Address - Country:US
Mailing Address - Phone:254-666-2292
Mailing Address - Fax:
Practice Address - Street 1:512 HEWITT DR
Practice Address - Street 2:
Practice Address - City:HEWITT
Practice Address - State:TX
Practice Address - Zip Code:76643-0296
Practice Address - Country:US
Practice Address - Phone:254-666-2292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2919152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093080202Medicaid