Provider Demographics
NPI:1083936058
Name:BLAKE AND FRANKLIN MD PA
Entity Type:Organization
Organization Name:BLAKE AND FRANKLIN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:O
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-683-5567
Mailing Address - Street 1:505 MARTIN LUTHER KING JR AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33815
Mailing Address - Country:US
Mailing Address - Phone:863-683-5567
Mailing Address - Fax:863-686-5814
Practice Address - Street 1:505 MARTIN LUTHER KING JR AVE
Practice Address - Street 2:STE 2
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33815
Practice Address - Country:US
Practice Address - Phone:863-683-5567
Practice Address - Fax:863-686-5814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0016779208D00000X
FLME0030612208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD52518Medicare UPIN
FLD61780Medicare UPIN