MEDICARE: DR. BLAKE B O'LAVIN 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	174400000X	Specialist	E3392	TX
2	2084B0040X	Behavioral Neurology & Neuropsychiatry Physician	E3392	TX
3	2084N0600X	Clinical Neurophysiology Physician	E3392	TX
4	2084D0003X	Diagnostic Neuroimaging (Psychiatry & Neurology) Physician	E3392	TX
5	2084N0008X	Neuromuscular Medicine (Psychiatry & Neurology) Physician	E3392	TX
6	2084P2900X	Pain Medicine (Psychiatry & Neurology) Physician	E3392	TX
7	2084S0012X	Sleep Medicine (Psychiatry & Neurology) Physician	E3392	TX
8	2084N0400X	Neurology Physician	E3392	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	130010206	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	812585	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1093709578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE B O'LAVIN M.D.

Provider Business Mailing Address
First Line	:	409 COLONY DR
Second Line	:	SUITE 402
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78412-2674
Country	:	US
Telephone Number	:	361-883-1731
Fax Number	:	361-883-1440

Provider Business Practice Location Address
First Line	:	409 COLONY DR
Second Line	:	SUITE 402
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78412-2674
Country	:	US
Telephone Number	:	361-883-1731
Fax Number	:	361-883-1440

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

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	12/13/2016

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Directions to “ DR. BLAKE B O'LAVIN M.D.” Practice Location

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