Provider Demographics
NPI:1316972458
Name:BLAKE, PHILMORE
Entity type:Individual
Prefix:
First Name:PHILMORE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 ABNER JACKSON PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5160
Mailing Address - Country:US
Mailing Address - Phone:979-297-9488
Mailing Address - Fax:979-297-9185
Practice Address - Street 1:188 ABNER JACKSON PKWY
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5160
Practice Address - Country:US
Practice Address - Phone:979-297-9488
Practice Address - Fax:979-297-9185
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7246208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0315798-01Medicaid
TXG87558Medicare UPIN
TX0315798-01Medicaid