Provider Demographics
NPI:1962404244
Name:BLAIR, STEPHEN D (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:BLAIR
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 1:100 W DEAN KEETON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1091
Mailing Address - Country:US
Mailing Address - Phone:512-471-4955
Mailing Address - Fax:
Practice Address - Street 1:505 W LOUIS HENNA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728-1702
Practice Address - Country:US
Practice Address - Phone:855-481-8375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8462207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092383101Medicaid
TX612912Medicare PIN
TXG57248Medicare UPIN