Provider Demographics
NPI:1063402063
Name:BLAIR, TERRY BRUCE (OD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:BRUCE
Last Name:BLAIR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3800 N MESA ST
Mailing Address - Street 2:STE B1
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1535
Mailing Address - Country:US
Mailing Address - Phone:915-533-1811
Mailing Address - Fax:915-533-3641
Practice Address - Street 1:3800 N MESA
Practice Address - Street 2:STE C8
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902
Practice Address - Country:US
Practice Address - Phone:915-533-1811
Practice Address - Fax:915-533-3641
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2777T6152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
908516OtherBLOCK VISION
117935OtherEYEMED VISION
TX80783QOtherBLUE CROSS BLUE SHIELD
NMP0902Medicaid
TX112454704Medicaid
143566OtherCOLE VISION
117935OtherEYEMED VISION
4722920001Medicare ID - Type UnspecifiedPALMETTO DEMRC
P00078885Medicare ID - Type UnspecifiedRAILROAD
TX112454704Medicaid