Provider Demographics
NPI:1992019301
Name:GOLSON, BLAKE ELLIOT (OD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:ELLIOT
Last Name:GOLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 W WADLEY AVE
Mailing Address - Street 2:22
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-6438
Mailing Address - Country:US
Mailing Address - Phone:432-684-7287
Mailing Address - Fax:432-684-7297
Practice Address - Street 1:2200 W WADLEY AVE
Practice Address - Street 2:22
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-6438
Practice Address - Country:US
Practice Address - Phone:432-684-7287
Practice Address - Fax:432-684-7297
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7598T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist