Provider Demographics
NPI:1225617657
Name:BASSETT, BLAKE (DO)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:BASSETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL AIR STATION NORTH ISLAND
Mailing Address - Street 2:28-64 S R AVE
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:73003
Mailing Address - Country:US
Mailing Address - Phone:619-545-6210
Mailing Address - Fax:
Practice Address - Street 1:NAVAL AIR STATION NORTH ISLAND
Practice Address - Street 2:28-64 S R AVE
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118
Practice Address - Country:US
Practice Address - Phone:619-545-6210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-04
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102207484208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
1OtherN/A