Provider Demographics
NPI:1477545127
Name:BLAKE, JEFFREY M (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:M
Last Name:BLAKE
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 1:14540 PRAIRIE LAKES BLVD N STE 110
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-4370
Mailing Address - Country:US
Mailing Address - Phone:317-982-5222
Mailing Address - Fax:317-982-5223
Practice Address - Street 1:14540 PRAIRIE LAKES BLVD N STE 110
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4370
Practice Address - Country:US
Practice Address - Phone:317-982-5222
Practice Address - Fax:317-982-5223
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040057A207VG0400X, 207VF0040X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300085297Medicaid
IN100172960Medicaid
INM55843044Medicare PIN