Provider Demographics
NPI:1477857670
Name:THOMAS B BLAKE III MD PA
Entity Type:Organization
Organization Name:THOMAS B BLAKE III MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:407-629-5141
Mailing Address - Street 1:331 N MAITLAND AVE
Mailing Address - Street 2:STE A-2
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4762
Mailing Address - Country:US
Mailing Address - Phone:407-629-5141
Mailing Address - Fax:407-629-5858
Practice Address - Street 1:331 N MAITLAND AVE
Practice Address - Street 2:STE A-2
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4762
Practice Address - Country:US
Practice Address - Phone:407-629-5141
Practice Address - Fax:407-629-5858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty