Provider Demographics
NPI:1487681342
Name:BAXTER, BLAISE W (MD)
Entity Type:Individual
Prefix:
First Name:BLAISE
Middle Name:W
Last Name:BAXTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:415-600-7887
Mailing Address - Fax:415-369-1395
Practice Address - Street 1:1100 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6978
Practice Address - Country:US
Practice Address - Phone:415-600-7887
Practice Address - Fax:415-369-1395
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN314162085R0202X
CAC1715042085R0202X
RIMD193822085R0204X
PAMD4684162085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC171504OtherSTATE MEDICAL LICENSE
TN3138130OtherPLAZA BC/BS OF TN
TN3132171OtherADR BC/BS OF TN
GA000842586OtherGA MCAID FOR BOTH
TNP00089428OtherRR MCARE-CI
TN300103477OtherRR MCARE-ADR
TN3840177Medicaid
AL009933179OtherAL CAID ADR ONLY
TN300103477Medicare PIN
TNP00089428OtherRR MCARE-CI
TN3840176Medicare PIN
TN3138130OtherPLAZA BC/BS OF TN
TN3840177Medicare PIN