MEDICARE: LORENZO GUSTAVO BLAS 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	2084N0400X	Neurology Physician	M9866	TX

General Provider Information

NPI Number	:	1760698583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORENZO GUSTAVO BLAS M.D.

Provider Business Mailing Address
First Line	:	4015 INTERSTATE 45 N STE 110
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-5076
Country	:	US
Telephone Number	:	936-270-3900
Fax Number	:	936-271-1584

Provider Business Practice Location Address
First Line	:	4015 INTERSTATE 45 N STE 110
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-5076
Country	:	US
Telephone Number	:	936-270-3900
Fax Number	:	936-271-1584

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	03/23/2023

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