Provider Demographics
NPI:1659697431
Name:RICHARDSON, BLAKELY S (DO)
Entity Type:Individual
Prefix:DR
First Name:BLAKELY
Middle Name:S
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2559 WESTERN TRAILS BLVD
Mailing Address - Street 2:STE 301
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1565
Mailing Address - Country:US
Mailing Address - Phone:512-815-2559
Mailing Address - Fax:
Practice Address - Street 1:2559 WESTERN TRAILS BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1565
Practice Address - Country:US
Practice Address - Phone:512-815-2559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXP7024207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP7024OtherTEXAS STATE LICENSE