Provider Demographics
NPI:1093418402
Name:WINDHAM, BLAKE KENT (MD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:KENT
Last Name:WINDHAM
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 1:202 ASHLEY PL
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5338
Mailing Address - Country:US
Mailing Address - Phone:228-219-1119
Mailing Address - Fax:
Practice Address - Street 1:202 ASHLEY PL
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5338
Practice Address - Country:US
Practice Address - Phone:228-219-1119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program