Provider Demographics
NPI:1558820357
Name:DAVIDSON, BLAKE MATTHEW (MD)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:MATTHEW
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7619 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4133
Mailing Address - Country:US
Mailing Address - Phone:866-413-9534
Mailing Address - Fax:260-407-4428
Practice Address - Street 1:1000 S LIMESTONE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-1179
Practice Address - Country:US
Practice Address - Phone:859-323-5901
Practice Address - Fax:859-323-3040
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY55656207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine