Provider Demographics
NPI:1861660094
Name:BROOKS M. BLAKE, DO, PA
Entity Type:Organization
Organization Name:BROOKS M. BLAKE, DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKS
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLKAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:830-798-8000
Mailing Address - Street 1:1009 FALLS PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-4630
Mailing Address - Country:US
Mailing Address - Phone:830-798-8000
Mailing Address - Fax:830-798-1075
Practice Address - Street 1:1009 FALLS PKWY STE B
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-4630
Practice Address - Country:US
Practice Address - Phone:830-798-8000
Practice Address - Fax:830-798-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty