Provider Demographics
NPI:1417844176
Name:MIRELES, BLAKE (MD, MSC)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:MIRELES
Suffix:
Gender:M
Credentials:MD, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6903 ALPERT DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-3603
Mailing Address - Country:US
Mailing Address - Phone:915-479-2167
Mailing Address - Fax:
Practice Address - Street 1:2501 N ORANGE AVE STE 235
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4659
Practice Address - Country:US
Practice Address - Phone:407-576-8068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL43612390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program