Provider Demographics
NPI:1679539142
Name:FERRARACCIO, BLAISE EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAISE
Middle Name:EDWARD
Last Name:FERRARACCIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4848 NE STALLINGS DR STE 106
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1256
Mailing Address - Country:US
Mailing Address - Phone:936-559-9510
Mailing Address - Fax:936-559-9598
Practice Address - Street 1:4848 NE STALLINGS DR STE 106
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1256
Practice Address - Country:US
Practice Address - Phone:936-559-9510
Practice Address - Fax:936-559-9598
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL80552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162235901Medicaid