Provider Demographics
NPI:1568811636
Name:STREET, BLAYNE K (DO)
Entity Type:Individual
Prefix:DR
First Name:BLAYNE
Middle Name:K
Last Name:STREET
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:301 JENNY GEORGE LN
Mailing Address - Street 2:BUILDING B, SUITE 5
Mailing Address - City:SWEETWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79556-7152
Mailing Address - Country:US
Mailing Address - Phone:325-219-6175
Mailing Address - Fax:325-219-6179
Practice Address - Street 1:301 JENNY GEORGE LANE
Practice Address - Street 2:BUILDING B, SUITE 5
Practice Address - City:SWEETWATER
Practice Address - State:TX
Practice Address - Zip Code:79556
Practice Address - Country:US
Practice Address - Phone:325-219-6175
Practice Address - Fax:325-219-6179
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2022-06-13
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Provider Licenses
StateLicense IDTaxonomies
TXS6314207QS0010X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX426407901Medicaid