Provider Demographics
NPI:1396884979
Name:BRANDON BLAKER O D P C
Entity type:Organization
Organization Name:BRANDON BLAKER O D P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLAKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:830-741-2634
Mailing Address - Street 1:205B W WATER ST
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028
Mailing Address - Country:US
Mailing Address - Phone:830-896-4044
Mailing Address - Fax:830-257-6419
Practice Address - Street 1:1620 AVENUE M
Practice Address - Street 2:
Practice Address - City:HONDO
Practice Address - State:TX
Practice Address - Zip Code:78861-1756
Practice Address - Country:US
Practice Address - Phone:830-741-2634
Practice Address - Fax:830-257-6419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX6429TG332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4924720003Medicare NSC
TX4924720001Medicare NSC
TX1396884979Medicare NSC