Provider Demographics
NPI:1235224718
Name:BLAKE, STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
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 860554
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886
Mailing Address - Country:US
Mailing Address - Phone:904-346-3606
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:3625 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-399-6811
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0058519207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11460OtherBCBS
FL11460OtherBCBS
FLC65143Medicare UPIN