Provider Demographics
NPI:1053490219
Name:BLAKE, MARCIA ELLEN (OD)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:ELLEN
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 1:10225 S OAKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1915
Mailing Address - Country:US
Mailing Address - Phone:773-233-3892
Mailing Address - Fax:
Practice Address - Street 1:1903 W 103RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2624
Practice Address - Country:US
Practice Address - Phone:773-233-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-006808152W00000X
MN1664152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38998Medicare UPIN
IL779475Medicare ID - Type Unspecified