Provider Demographics
NPI:1871023051
Name:BLAKE, DOUGLAS LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:LEE
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PA-C
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 2031
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2031
Mailing Address - Country:US
Mailing Address - Phone:817-845-3587
Mailing Address - Fax:
Practice Address - Street 1:210 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-7134
Practice Address - Country:US
Practice Address - Phone:817-277-9597
Practice Address - Fax:817-277-3388
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05784207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine