Provider Demographics
NPI:1528358025
Name:BLANKENSHIP, ALAN L JR (MD)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:L
Last Name:BLANKENSHIP
Suffix:JR
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 1:6451 BRENTWOOD RD
Mailing Address - Street 2:STE 200
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112
Mailing Address - Country:US
Mailing Address - Phone:817-496-9700
Mailing Address - Fax:
Practice Address - Street 1:2700 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:682-622-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP4424207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX352927YLLYMedicare PIN