MEDICARE: LAKE JACKSON UROLOGY PA

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	208800000X	Urology Physician

General Provider Information

NPI Number	:	1558462812
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE JACKSON UROLOGY PA

Provider Business Mailing Address
First Line	:	188 ABNER JACKSON PKWY
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-5160
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	188 ABNER JACKSON PKWY
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-5160
Country	:	US
Telephone Number	:	979-297-9488
Fax Number	:	979-297-9185

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PHILMORE BLAKE
Credential	:
Telephone Number	:	979-297-9488

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/22/2020

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Directions to “LAKE JACKSON UROLOGY PA ” Practice Location

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