Provider Demographics
NPI:1568689263
Name:BLAKE, ANTHONY JOHN (DC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOHN
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HIGHVIEW RD
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-3103
Mailing Address - Country:US
Mailing Address - Phone:973-416-0200
Mailing Address - Fax:
Practice Address - Street 1:554 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1338
Practice Address - Country:US
Practice Address - Phone:973-483-2277
Practice Address - Fax:973-483-4577
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00339300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ065584Q97Medicare PIN