Provider Demographics
NPI:1124010301
Name:GRAVES, BLANE A (MD)
Entity Type:Individual
Prefix:DR
First Name:BLANE
Middle Name:A
Last Name:GRAVES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:1408 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3534
Practice Address - Country:US
Practice Address - Phone:903-794-0515
Practice Address - Fax:903-793-8000
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4402207Q00000X
ARE2697207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152744201Medicaid
TX430909809OtherNOVASYS
TX5L641OtherARKANSAS BLUE CROSS BLUE SHIELD
TX8K1368OtherTEXAS BLUE CROSS BLUE SHIELD
TX020900066-00OtherQUALCHOICE
TX080189370OtherRAILROAD MEDICARE
AR142180001Medicaid
TX8384B7Medicare PIN
TX080189370OtherRAILROAD MEDICARE