Provider Demographics
NPI:1487726568
Name:BLAKER, SHELLY (OD)
Entity type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:
Last Name:BLAKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 S. ADAMS
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4472
Mailing Address - Country:US
Mailing Address - Phone:830-997-2504
Mailing Address - Fax:830-997-5155
Practice Address - Street 1:508 S. ADAMS
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4472
Practice Address - Country:US
Practice Address - Phone:830-997-2504
Practice Address - Fax:830-997-5155
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6569TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170488401Medicaid
TX81131QOtherBCBS OF TEXAS
TXV0I757Medicare UPIN
TXP00088457Medicare ID - Type UnspecifiedRAILROAD MEDICARE
TX170488401Medicaid