Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 35095075 | OH |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | A106986 | CA |
NPI | 1124278668 |
---|---|
Provider Name | Dr. Brian J Blake |
First Address | Canton, OH 44718-3603 |
Second Address | Canton, OH 44718-3603 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2008 |
Last Update Date | 18/03/2011 |