Individual
KYLE MATTHEW BLAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
102 DECKER CT, SUITE 205, IRVING, TX 75062-2740
(972) 906-6250
Mailing address
102 DECKER CT, SUITE 205, IRVING, TX 75062-2740
(972) 906-6250
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
Q1362
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
341545705
—
TX
01
—
Q1362
LICENSE
TX
Enumeration date
05/26/2008
Last updated
01/10/2019
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