Provider Demographics
NPI:1801856158
Name:FAGALA-BLAKE, GWEN EILEEN (MD)
Entity type:Individual
Prefix:DR
First Name:GWEN
Middle Name:EILEEN
Last Name:FAGALA-BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650859, DEPT. 710
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0859
Mailing Address - Country:US
Mailing Address - Phone:409-772-2222
Mailing Address - Fax:
Practice Address - Street 1:400 HARBORSIDE DR STE 118-119
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-1990
Practice Address - Country:US
Practice Address - Phone:409-772-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH80272084P0805X, 2084P0800X, 2084P0800X
MO1053272084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry