Provider Demographics
NPI:1336469444
Name:ISERNHAGEN, BLAKE (MD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:ISERNHAGEN
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 1:120 N EAGLE CREEK DR
Mailing Address - Street 2:STE 500
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1827
Mailing Address - Country:US
Mailing Address - Phone:859-263-3900
Mailing Address - Fax:859-263-3757
Practice Address - Street 1:120 N EAGLE CREEK DR
Practice Address - Street 2:STE 500
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509
Practice Address - Country:US
Practice Address - Phone:859-263-3900
Practice Address - Fax:859-263-3757
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48761207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1336469444Medicaid
OH0163986Medicaid
OK200312510AMedicaid
IN300015774Medicaid
KY7100400550Medicaid