Provider Demographics
NPI:1558462812
Name:LAKE JACKSON UROLOGY PA
Entity Type:Organization
Organization Name:LAKE JACKSON UROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILMORE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-297-9488
Mailing Address - Street 1:188 ABNER JACKSON PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:188 ABNER JACKSON PKWY
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5160
Practice Address - Country:US
Practice Address - Phone:979-297-9488
Practice Address - Fax:979-297-9185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty