Provider Demographics
NPI:1487639258
Name:BLACKSTONE, WILLIAM O (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:O
Last Name:BLACKSTONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 200993
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77216-0993
Mailing Address - Country:US
Mailing Address - Phone:281-784-1111
Mailing Address - Fax:281-784-1555
Practice Address - Street 1:8850 LONG POINT RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-3006
Practice Address - Country:US
Practice Address - Phone:713-722-3775
Practice Address - Fax:713-722-3731
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2984207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135667709Medicaid
TX1487639258OtherTRICARE SOUTH
TX8Z2091OtherBCBSTX PROV NO
TX1487639258OtherBCBSTX
TX1487639258Medicare PIN
TX930125581Medicare PIN
TX1487639258OtherBCBSTX
TXC13505Medicare UPIN