Provider Demographics
NPI:1093894230
Name:BLAKER, BRANDON (OD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:BLAKER
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 1:205-B WEST WATER ST.
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028
Mailing Address - Country:US
Mailing Address - Phone:830-896-4044
Mailing Address - Fax:830-257-6419
Practice Address - Street 1:205-B WEST WATER ST.
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028
Practice Address - Country:US
Practice Address - Phone:830-896-4044
Practice Address - Fax:830-257-6419
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6429TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32624OtherCHIPS/COMMFIRST
TX32648OtherCHIPS/STAR
TXTX6429OtherEYEMED
TXTX6429OtherCOLE
TX80598QOtherBCBS
TX160081902Medicaid
TXP00121646OtherRAILROAD MEDICARE
TXTX6429OtherCOLE
TX8B2865Medicare ID - Type Unspecified