Provider Demographics
NPI:1639690605
Name:BLAKELY, BRETT MATTHEW (DO)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:MATTHEW
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8903 MANTON AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4120
Mailing Address - Country:US
Mailing Address - Phone:248-953-4326
Mailing Address - Fax:
Practice Address - Street 1:835 SWEITZER ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1007
Practice Address - Country:US
Practice Address - Phone:937-548-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101023615207P00000X
MI5151009691207P00000X
OH34.015322207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine