Provider Demographics
NPI:1578191250
Name:BLAKE, MATTHEW DANIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DANIEL
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1210 KY HIGHWAY 36 E UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-7498
Mailing Address - Country:US
Mailing Address - Phone:859-234-2300
Mailing Address - Fax:859-235-3699
Practice Address - Street 1:1210 KY HIGHWAY 36 E UNIT 1
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-7498
Practice Address - Country:US
Practice Address - Phone:859-234-2300
Practice Address - Fax:859-235-3699
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY05539207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine