Provider Demographics
NPI:1073510012
Name:BEAZER, BLAKE RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:RICHARD
Last Name:BEAZER
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 1:2356 N 400 E
Mailing Address - Street 2:STE 201
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074
Mailing Address - Country:US
Mailing Address - Phone:435-882-2350
Mailing Address - Fax:435-882-2039
Practice Address - Street 1:2356 N 400 E
Practice Address - Street 2:STE 201
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-882-2350
Practice Address - Fax:435-882-2039
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5248080-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4916Medicaid
UT005728901Medicare ID - Type Unspecified
H53787Medicare UPIN