MEDICARE: MR. DOUGLAS LEE BLAKE PA-C

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	207Q00000X	Family Medicine Physician	PA05784	TX

General Provider Information

NPI Number	:	1871023051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS LEE BLAKE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 2031
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76113-2031
Country	:	US
Telephone Number	:	817-845-3587
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 W SOUTH ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76010-7134
Country	:	US
Telephone Number	:	817-277-9597
Fax Number	:	817-277-3388

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

Provider Enumeration Date	:	06/19/2017
Last Update Date	:	12/07/2025

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