Provider Demographics
NPI:1568783777
Name:MARVIN, BLAKE ADAM (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:ADAM
Last Name:MARVIN
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 1:2005 KNIGHT LANE, BUILDING H, ATTN: MEDICAL STAFF SERVI
Mailing Address - Street 2:NAVY MEDICINE SUPPORT COMMAND
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212
Mailing Address - Country:US
Mailing Address - Phone:760-725-8882
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL BEAUFORT
Practice Address - Street 2:1 PICKNEY BLVD
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902
Practice Address - Country:US
Practice Address - Phone:843-228-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1103207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine