Provider Demographics
NPI:1881641975
Name:BLAKESTAD, BLAINE RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:RANDALL
Last Name:BLAKESTAD
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 1:702 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-8853
Mailing Address - Country:US
Mailing Address - Phone:936-639-7861
Mailing Address - Fax:936-639-7352
Practice Address - Street 1:1201 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3357
Practice Address - Country:US
Practice Address - Phone:936-639-7696
Practice Address - Fax:936-639-7352
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF13912083P0011X, 208G00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214434701Medicaid
TX8F6127OtherBLUE CROSS
TXB104939Medicare PIN