Provider Demographics
NPI:1912904731
Name:KRELL, BLAIR WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:WILLIAM
Last Name:KRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 PARKING WAY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5227
Mailing Address - Country:US
Mailing Address - Phone:979-299-3376
Mailing Address - Fax:979-299-3197
Practice Address - Street 1:214 PARKING WAY ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5227
Practice Address - Country:US
Practice Address - Phone:979-299-3376
Practice Address - Fax:979-299-3797
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1637174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143723801Medicaid
TX302679101OtherMHS PHYS OF TX BRAZORIA MDCD GRP TPI
TX0035TDOtherMHS PHYS OF TX BCBSTX GRP PROV REC
TX8A4379Medicare ID - Type Unspecified
TX143723801Medicaid
TXH37860Medicare UPIN