Basic Information
Provider Information | |||||||||
NPI: | 1396884979 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRANDON BLAKER O D P C | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HILL COUNTRY VISION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 205B W WATER ST | ||||||||
Address2: |   | ||||||||
City: | KERRVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 78028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8308964044 | ||||||||
FaxNumber: | 8302576419 | ||||||||
Practice Location | |||||||||
Address1: | 1620 AVENUE M | ||||||||
Address2: |   | ||||||||
City: | HONDO | ||||||||
State: | TX | ||||||||
PostalCode: | 788611756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8307412634 | ||||||||
FaxNumber: | 8302576419 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2007 | ||||||||
LastUpdateDate: | 07/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLAKER | ||||||||
AuthorizedOfficialFirstName: | BRANDON | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8307412634 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | O.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | TX6429TG | TX | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
No ID Information.