MEDICARE: DR. BROOKE BLAKE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	BP10053401	TX

General Provider Information

NPI Number	:	1346622834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BROOKE BLAKE M.D.

Provider Business Mailing Address
First Line	:	1861 OLD SPANISH TRL
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2001
Country	:	US
Telephone Number	:	832-927-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1861 OLD SPANISH TRL
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2001
Country	:	US
Telephone Number	:	832-927-5000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2015
Last Update Date	:	06/10/2019

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Directions to “ DR. BROOKE BLAKE M.D.” Practice Location

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