Provider Demographics
NPI:1063448405
Name:GEREN, BLAKE NORTON (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:NORTON
Last Name:GEREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4281
Mailing Address - Country:US
Mailing Address - Phone:479-782-8892
Mailing Address - Fax:479-782-8840
Practice Address - Street 1:7901 DALLAS ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4281
Practice Address - Country:US
Practice Address - Phone:479-782-8892
Practice Address - Fax:479-782-8840
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5157207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CQ2484OtherRAILROAD MEDICARE
OK200115630AMedicaid
ARP00419389OtherRAILROAD MEDICARE
AR164798001Medicaid
AR164798001Medicaid