Provider Demographics
NPI:1104037100
Name:BLAIR, MICHAEL MONTGOMERY (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MONTGOMERY
Last Name:BLAIR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 WONDER WORLD DR STE 4031
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7598
Mailing Address - Country:US
Mailing Address - Phone:512-353-6400
Mailing Address - Fax:
Practice Address - Street 1:1340 WONDER WORLD DR STE 4031
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7598
Practice Address - Country:US
Practice Address - Phone:512-353-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0551207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287444801Medicaid
TXP00995618OtherRR MEDICARE
TXTXB140444OtherMEDICARE