Provider Demographics
NPI:1033192240
Name:BLAKE, JULIE M (OD)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 12TH CT S
Mailing Address - Street 2:A3
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35222-4524
Mailing Address - Country:US
Mailing Address - Phone:205-324-9269
Mailing Address - Fax:
Practice Address - Street 1:3431 COLONNADE PKWY
Practice Address - Street 2:C2
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-3232
Practice Address - Country:US
Practice Address - Phone:205-967-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALSB05TA700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist