Provider Demographics
NPI:1154844504
Name:IRELAND, BLAKE VICENT
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:VICENT
Last Name:IRELAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1604
Mailing Address - Country:US
Mailing Address - Phone:203-757-0636
Mailing Address - Fax:
Practice Address - Street 1:158 HARMON DR
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:VT
Practice Address - Zip Code:05663-1000
Practice Address - Country:US
Practice Address - Phone:203-565-1815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program