Provider Demographics
NPI:1083216949
Name:WALLACE, BLAKE TAYLOR (DPM)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:TAYLOR
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8414 NAAB RD STE 215
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1972
Mailing Address - Country:US
Mailing Address - Phone:317-338-7510
Mailing Address - Fax:
Practice Address - Street 1:8414 NAAB RD STE 215
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1972
Practice Address - Country:US
Practice Address - Phone:317-338-7510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty