Provider Demographics
NPI:1215559331
Name:JON KEVIN BLAKE MD
Entity Type:Organization
Organization Name:JON KEVIN BLAKE MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-674-7889
Mailing Address - Street 1:PO BOX 1889
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47308-1889
Mailing Address - Country:US
Mailing Address - Phone:765-284-0493
Mailing Address - Fax:
Practice Address - Street 1:925 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GAS CITY
Practice Address - State:IN
Practice Address - Zip Code:46933-1550
Practice Address - Country:US
Practice Address - Phone:765-674-7889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty