Provider Demographics
NPI:1235392275
Name:BLAKE, KATHLEEN DEGROFT (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DEGROFT
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 COUNTRY CLUB RD.
Mailing Address - Street 2:SUITE A PEDIATRIC ASSOCIATES INC
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213
Mailing Address - Country:US
Mailing Address - Phone:614-501-7337
Mailing Address - Fax:614-434-2726
Practice Address - Street 1:1021 COUNTRY CLUB RD
Practice Address - Street 2:SUITE A PEDIATRIC ASSOCIATES INC
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213
Practice Address - Country:US
Practice Address - Phone:614-501-7337
Practice Address - Fax:614-434-2726
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35088684208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics