Provider Demographics
NPI:1083720965
Name:BLAKE, RHONDA J (OD)
Entity Type:Individual
Prefix:DR
First Name:RHONDA
Middle Name:J
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 1:12026 BIRD KEY BLVD
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-4181
Mailing Address - Country:US
Mailing Address - Phone:317-594-0779
Mailing Address - Fax:
Practice Address - Street 1:7325 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-3245
Practice Address - Country:US
Practice Address - Phone:317-202-9738
Practice Address - Fax:317-202-9741
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003197152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist