Provider Demographics
NPI:1225304322
Name:BLAKE, KATHERINE M (DO)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:131 E PARK AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2858
Mailing Address - Country:US
Mailing Address - Phone:847-984-3290
Mailing Address - Fax:847-255-2015
Practice Address - Street 1:131 E PARK AVE STE 103
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2858
Practice Address - Country:US
Practice Address - Phone:847-984-3290
Practice Address - Fax:847-255-2015
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-061735207Q00000X
WI64086207Q00000X
IL036136377207QB0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine