Healthcare Provider Details

I. General information

NPI: 1528358025
Provider Name (Legal Business Name): ALAN L BLANKENSHIP JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 E BROAD ST
MANSFIELD TX
76063
US

IV. Provider business mailing address

6451 BRENTWOOD RD STE 200
FT WORTH TX
76112
US

V. Phone/Fax

Practice location:
  • Phone: 682-622-2000
  • Fax:
Mailing address:
  • Phone: 817-496-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberP4424
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: