Provider Demographics
NPI:1376772707
Name:BLAKE, BRETT PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:PATRICK
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:15051 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-5182
Mailing Address - Country:US
Mailing Address - Phone:239-437-8810
Mailing Address - Fax:239-313-2555
Practice Address - Street 1:4002 SUN CITY CENTER BLVD
Practice Address - Street 2:UNIT 102
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5256
Practice Address - Country:US
Practice Address - Phone:813-634-1455
Practice Address - Fax:813-642-8355
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2016-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME125767207N00000X
390200000X
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIK676ZMedicare PIN