Healthcare Provider Details

I. General information

NPI: 1205773405
Provider Name (Legal Business Name): ETHAN BLYTHE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 PROVIDENCE DR
WACO TX
76707-2261
US

IV. Provider business mailing address

4807 PIN OAK PARK APT 10305
HOUSTON TX
77081-2178
US

V. Phone/Fax

Practice location:
  • Phone: 254-313-4200
  • Fax: 254-313-4383
Mailing address:
  • Phone: 254-313-4200
  • Fax: 254-313-4383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: