Provider Demographics
NPI:1295231413
Name:GILLILAND, BLAKE AARON
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:AARON
Last Name:GILLILAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 FOREST BANK LN
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-5283
Mailing Address - Country:US
Mailing Address - Phone:281-254-3911
Mailing Address - Fax:
Practice Address - Street 1:7703 FLOYD CURL DR.
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-567-1183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS4954207P00000X
TXBP10062833390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBP10062833OtherTEXAS PHYSICIAN IN TRAINING PERMIT
TXS4954OtherSTATE