Provider Demographics
NPI:1316006091
Name:BRANDON BLAKER O D P C
Entity Type:Organization
Organization Name:BRANDON BLAKER O D P C
Other - Org Name:HILL COUNTRY VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:830-896-2600
Mailing Address - Street 1:205B W WATER ST
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-4252
Mailing Address - Country:US
Mailing Address - Phone:830-896-2600
Mailing Address - Fax:
Practice Address - Street 1:205B W WATER ST
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-4252
Practice Address - Country:US
Practice Address - Phone:830-896-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162788701Medicaid
TX86FCOtherBLUE CROSS BLUE SHIELD
TX00956VMedicare ID - Type Unspecified
TX162788701Medicaid