Provider Demographics
NPI:1073653820
Name:JONATHAN BLAU MD PA
Entity Type:Organization
Organization Name:JONATHAN BLAU MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-593-6500
Mailing Address - Street 1:PO BOX 6547
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6547
Mailing Address - Country:US
Mailing Address - Phone:903-593-6500
Mailing Address - Fax:903-531-9535
Practice Address - Street 1:1814 ROSELAND BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4234
Practice Address - Country:US
Practice Address - Phone:903-593-6500
Practice Address - Fax:903-531-9535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ47212081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163743101Medicaid
TX6264980001Medicare NSC
TX8B2513Medicare ID - Type Unspecified
TX163743101Medicaid