Provider Demographics
NPI:1609856384
Name:SMITH, BLAKE T (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:T
Last Name:SMITH
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 201606
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-1606
Mailing Address - Country:US
Mailing Address - Phone:972-519-1940
Mailing Address - Fax:
Practice Address - Street 1:3901 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7738
Practice Address - Country:US
Practice Address - Phone:972-519-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6644207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BZ638OtherBCBS
TX159013502Medicaid
TX159013503Medicaid
TXP00802524OtherRAILROAD
TX159013507Medicaid
TX8J1771OtherBCBS
TX159013502Medicaid
TX159013507Medicaid
TX8J1771OtherBCBS
TX159013503Medicaid