Provider Demographics
NPI:1164435236
Name:BLAKE, BROOKS M (DO)
Entity Type:Individual
Prefix:
First Name:BROOKS
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1800 MORMON MILL RD
Mailing Address - Street 2:STE A6
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-4175
Mailing Address - Country:US
Mailing Address - Phone:830-798-8000
Mailing Address - Fax:830-798-8120
Practice Address - Street 1:1800 MORMON MILL RD
Practice Address - Street 2:STE A6
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-4175
Practice Address - Country:US
Practice Address - Phone:830-798-8000
Practice Address - Fax:830-798-8120
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL4187204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0041KCOtherBLUE CROSS BLUE SHIELD
TXH66458Medicare UPIN
TX0041KCOtherBLUE CROSS BLUE SHIELD