Provider Demographics
NPI:1164431185
Name:BLAKE, JEFFREY W (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:BLAKE
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:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32035-0517
Mailing Address - Country:US
Mailing Address - Phone:904-548-1800
Mailing Address - Fax:904-277-7286
Practice Address - Street 1:1620 NECTARINE ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4724
Practice Address - Country:US
Practice Address - Phone:904-548-1860
Practice Address - Fax:904-277-7283
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLL478207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE1353ZMedicare ID - Type Unspecified
FLC07193Medicare UPIN