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NPI Code Detail

MEDICARE: MR. ETHAN BLYTHE MD

MEDICARE: MR. ETHAN BLYTHE MD
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
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1205773405
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. ETHAN BLYTHE MD
Provider Business Mailing Address
First Line : 4807 PIN OAK PARK APT 10305
Second Line :
City : HOUSTON
State : TX
Zip : 77081-2178
Country : US
Telephone Number : 254-313-4200
Fax Number : 254-313-4383
Provider Business Practice Location Address
First Line : 1600 PROVIDENCE DR
Second Line :
City : WACO
State : TX
Zip : 76707-2261
Country : US
Telephone Number : 254-313-4200
Fax Number : 254-313-4383
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/04/2026
Last Update Date : 05/04/2026

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