Provider Demographics
NPI:1508826587
Name:BLAKE, JOHN S (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
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 1:210 W 300 N 7-3
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066
Mailing Address - Country:US
Mailing Address - Phone:435-722-3971
Mailing Address - Fax:435-722-6104
Practice Address - Street 1:210 W 300 N 7-3
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066
Practice Address - Country:US
Practice Address - Phone:435-722-3971
Practice Address - Fax:435-722-6104
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49109901205207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD3948Medicaid
UTE49176Medicare UPIN
UT006486031Medicare ID - Type Unspecified
UTD3948Medicaid