Provider Demographics
NPI:1417172842
Name:DUGGER, BLAKE W (DC)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:W
Last Name:DUGGER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22078 E COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-6506
Mailing Address - Country:US
Mailing Address - Phone:618-535-9125
Mailing Address - Fax:618-254-9351
Practice Address - Street 1:3412 NAMEOKI RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3702
Practice Address - Country:US
Practice Address - Phone:618-876-7800
Practice Address - Fax:618-876-7800
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009154111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210366Medicare PIN
ILK12461Medicare UPIN