Provider Demographics
NPI:1497067540
Name:BLAKE, SEAN (DO)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 MANCHESTER EXPY STE 101A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6802
Mailing Address - Country:US
Mailing Address - Phone:706-322-6646
Mailing Address - Fax:706-322-2891
Practice Address - Street 1:2300 MANCHESTER EXPY STE 101A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6802
Practice Address - Country:US
Practice Address - Phone:706-322-6646
Practice Address - Fax:706-322-2891
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069875207X00000X, 2086S0105X, 207XS0106X
TXS0431207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52606838-001OtherBCBSGA
AL600-88733OtherBCBS-AL
GA069875OtherMEDICAL LICENSE
TXS0431OtherTX MEDICAL LICENSE
GA202I204646OtherMEDICARE PTAN