Provider Demographics
NPI:1235121864
Name:BLANK, WILLIAM FREDERICK III (DPM)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:FREDERICK
Last Name:BLANK
Suffix:III
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21175 STATE HIGHWAY 249 # 192
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-1655
Mailing Address - Country:US
Mailing Address - Phone:713-254-2883
Mailing Address - Fax:713-426-2034
Practice Address - Street 1:18960 N MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-4216
Practice Address - Country:US
Practice Address - Phone:281-540-6322
Practice Address - Fax:713-426-2034
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1416213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112184002Medicaid
P00381651OtherRAILROAD MEDICARE
TX112184003Medicaid
TX112184003Medicaid
TX00589EMedicare PIN