Healthcare Provider Details

I. General information

NPI: 1962404244
Provider Name (Legal Business Name): STEPHEN D BLAIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 W LOUIS HENNA BLVD STE 100
AUSTIN TX
78728-1702
US

IV. Provider business mailing address

100 W DEAN KEETON ST STE 100
AUSTIN TX
78712-1091
US

V. Phone/Fax

Practice location:
  • Phone: 855-481-8375
  • Fax:
Mailing address:
  • Phone: 512-471-4955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ8462
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: