Basic Information
| Provider Information | |||||||||
| NPI: | 1740540814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUTTON | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | AARON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11538 | ||||||||
| Address2: | |||||||||
| City: | KILLEEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765471538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542459177 | ||||||||
| FaxNumber: | 2542459178 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 S W S YOUNG DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | KILLEEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765423340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542459175 | ||||||||
| FaxNumber: | 2542137771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Q9253 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | Q9253 | TX | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207L00000X | BP10043700 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 368548903 | 05 | TX | MEDICAID |