Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | L4187 | TX |
NPI | 1164435236 |
---|---|
Provider Name | Brooks M Blake |
First Address | Marble Falls, TX 78654-4175 |
Second Address | Marble Falls, TX 78654-4175 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0041KC | BLUE CROSS BLUE SHIELD (01) | TX |
H66458 | (02) | TX |