Organization Name: | WENDELL O BLAKE MD PA |
NPI Number: | 1700213972 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | WENDELL O BLAKE (PRESIDENT) |
Mailing Address: | 505 Martin Luther King Jr Avenue Suite 2 Lakeland |
State: | FL US |
Postal Code: | 338151527 |
Phone Number: | 8636835567 |
Fax Number: | 8636865814 |
NPI Enumeration Date: | 10/03/2013 |
NPI Last Update Date: | 10/03/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | ME0016779 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | FL |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |