Provider Demographics
NPI:1588827166
Name:VICTOR J BLAKE & ASSOCIATES
Entity type:Organization
Organization Name:VICTOR J BLAKE & ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-996-7622
Mailing Address - Street 1:1897 GODBY RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-5235
Mailing Address - Country:US
Mailing Address - Phone:770-996-7622
Mailing Address - Fax:770-996-5469
Practice Address - Street 1:1897 GODBY RD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5235
Practice Address - Country:US
Practice Address - Phone:770-996-7622
Practice Address - Fax:770-996-5469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0510780207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000685935HMedicaid
GA11BDKNHMedicare UPIN