Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207V00000X | Obstetrician & Gynecologist | 01040057A | IN |
Y | 207VF0040X | Female Pelvic Medicine and Reconstructive Surgeon | 01040057A | IN |
N | 207VG0400X | Gynecologist | 01040057A | IN |
NPI | 1477545127 |
---|---|
Provider Name | Jeffrey M Blake |
First Address | Indianapolis, IN 46268-3129 |
Second Address | Anderson, IN 46016-4389 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2005 |
Last Update Date | 04/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100172960 | (05) | IN |
F35406 | (02) |