Provider Demographics
NPI:1336120237
Name:BLAKE, SIMONE P (OD)
Entity Type:Individual
Prefix:DR
First Name:SIMONE
Middle Name:P
Last Name:BLAKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6850 PERIMETER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-8051
Mailing Address - Country:US
Mailing Address - Phone:614-789-5559
Mailing Address - Fax:614-789-5758
Practice Address - Street 1:6850 PERIMETER DR
Practice Address - Street 2:SUITE A
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-8051
Practice Address - Country:US
Practice Address - Phone:614-789-5559
Practice Address - Fax:614-789-5758
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5288152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2333139Medicaid
OH4086594Medicare PIN
OHU90795Medicare UPIN