Provider Demographics
NPI:1659327609
Name:BLAKESLEE, KIMBERLY (DO)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:BLAKESLEE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:RAVITZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2827 FORT MISSOULA RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7408
Mailing Address - Country:US
Mailing Address - Phone:406-728-4100
Mailing Address - Fax:
Practice Address - Street 1:2230 N RESERVE ST
Practice Address - Street 2:SUITE 402
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1321
Practice Address - Country:US
Practice Address - Phone:406-721-0533
Practice Address - Fax:406-728-4463
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9618207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E92827Medicare UPIN