Provider Demographics
NPI:1952578064
Name:BLAKE, BRIAN KELLY (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KELLY
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 MAIN ST
Mailing Address - Street 2:SUITE 5200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4612
Mailing Address - Country:US
Mailing Address - Phone:800-362-2731
Mailing Address - Fax:214-712-2444
Practice Address - Street 1:1717 MAIN ST
Practice Address - Street 2:SUITE 5200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-4612
Practice Address - Country:US
Practice Address - Phone:800-362-2731
Practice Address - Fax:214-712-2444
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN9813207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK401449Medicare PIN