Provider Demographics
NPI:1508873787
Name:BLAKE, THOMAS B III (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
Last Name:BLAKE
Suffix:III
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 1:331 N MAITLAND AVE
Mailing Address - Street 2:SUITE 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:SUITE 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
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65263174400000X
GA033032174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
F88589Medicare UPIN
FL25600ZMedicare PIN
25600Medicare ID - Type Unspecified