Provider Demographics
NPI:1164764684
Name:WILLIAMS, BLAKE KENT (MD, CAQSM)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:KENT
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD, CAQSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8414 NAAB RD STE 120
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1972
Mailing Address - Country:US
Mailing Address - Phone:317-338-7584
Mailing Address - Fax:317-338-7494
Practice Address - Street 1:780 MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230
Practice Address - Country:US
Practice Address - Phone:413-528-8643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA272651207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine