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
StateLicense IDTaxonomies
IN01073180A2084N0400X
KY465462084N0400X
OH351216192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01347060OtherRR MEDICARE
OH0104892Medicaid
KY7100305370Medicaid
OH0104892Medicaid
KY7100305370Medicaid