Provider Demographics
NPI:1962688168
Name:SMITH-BLAIR, GAYLE LATRECE (MD)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:LATRECE
Last Name:SMITH-BLAIR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 W WHEATLAND RD
Mailing Address - Street 2:STE 235
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3470
Mailing Address - Country:US
Mailing Address - Phone:214-446-1240
Mailing Address - Fax:214-446-1244
Practice Address - Street 1:3450 W WHEATLAND RD
Practice Address - Street 2:STE 235
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3470
Practice Address - Country:US
Practice Address - Phone:214-446-1240
Practice Address - Fax:214-446-1244
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103TP0016X103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF20893Medicare UPIN