Provider Demographics
NPI:1003824483
Name:POWELL, TED BLAKE (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:BLAKE
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 RIVER BEND DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4915
Mailing Address - Country:US
Mailing Address - Phone:214-638-2000
Mailing Address - Fax:214-631-6724
Practice Address - Street 1:1600 HOSPITAL PARKWAY
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6913
Practice Address - Country:US
Practice Address - Phone:214-638-2000
Practice Address - Fax:214-631-6724
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8949207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83P491OtherBCBS
TX102314501Medicaid
TX220017764OtherRAILROAD MEDICARE
TX83P491Medicare ID - Type UnspecifiedLOCALITY 28
TX83P491OtherBCBS