Provider Demographics
NPI: | 1518192533 |
---|---|
Name: | SMITH, BLAKE ALLEN (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | BLAKE |
Middle Name: | ALLEN |
Last Name: | SMITH |
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: | 3113 BELLEVUE AVE FL 3 |
Mailing Address - Street 2: | |
Mailing Address - City: | CINCINNATI |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45219-3158 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 513-475-8730 |
Mailing Address - Fax: | 513-475-8033 |
Practice Address - Street 1: | 3113 BELLEVUE AVE FL 3 |
Practice Address - Street 2: | |
Practice Address - City: | CINCINNATI |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45219-3158 |
Practice Address - Country: | US |
Practice Address - Phone: | 513-475-8730 |
Practice Address - Fax: | 513-475-8033 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2009-05-19 |
Last Update Date: | 2023-11-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 01073180A | 2084N0400X |
KY | 46546 | 2084N0400X |
OH | 35121619 | 2084N0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
P01347060 | Other | RR MEDICARE | |
OH | 0104892 | Medicaid | |
KY | 7100305370 | Medicaid | |
OH | 0104892 | Medicaid | |
KY | 7100305370 | Medicaid |