Basic Information
| Provider Information | |||||||||
| NPI: | 1093894230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKER | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205-B WEST WATER ST. | ||||||||
| Address2: | |||||||||
| City: | KERRVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308964044 | ||||||||
| FaxNumber: | 8302576419 | ||||||||
| Practice Location | |||||||||
| Address1: | 205-B WEST WATER ST. | ||||||||
| Address2: | |||||||||
| City: | KERRVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308964044 | ||||||||
| FaxNumber: | 8302576419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6429TG | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 32624 | 01 | TX | CHIPS/COMMFIRST | OTHER | 32648 | 01 | TX | CHIPS/STAR | OTHER | TX6429 | 01 | TX | EYEMED | OTHER | TX6429 | 01 | TX | COLE | OTHER | 80598Q | 01 | TX | BCBS | OTHER | 160081902 | 05 | TX | MEDICAID | P00121646 | 01 | TX | RAILROAD MEDICARE | OTHER |