Provider Demographics
NPI:1447220363
Name:BLAKE, JOHN R JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:BLAKE
Suffix:JR
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 1:4306 ASHEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37914-3601
Mailing Address - Country:US
Mailing Address - Phone:865-522-2168
Mailing Address - Fax:865-522-7116
Practice Address - Street 1:4306 ASHEVILLE HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37914-3601
Practice Address - Country:US
Practice Address - Phone:865-522-2168
Practice Address - Fax:865-522-7116
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD16391207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3721704Medicaid
TN3015052Medicare ID - Type Unspecified
TN3721704Medicaid