Provider Demographics
NPI:1467471607
Name:WEIDAW, BLAKE ANN (MD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:ANN
Last Name:WEIDAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12174 N MOPAC EXPY
Mailing Address - Street 2:STE. A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2910
Mailing Address - Country:US
Mailing Address - Phone:512-994-2662
Mailing Address - Fax:512-994-2660
Practice Address - Street 1:12174 N MOPAC EXPY
Practice Address - Street 2:STE. A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2910
Practice Address - Country:US
Practice Address - Phone:512-994-2662
Practice Address - Fax:512-994-2660
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXTEMP207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology