Provider Demographics
NPI:1700213972
Name:WENDELL O BLAKE MD PA
Entity Type:Organization
Organization Name:WENDELL O BLAKE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:O
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-683-5567
Mailing Address - Street 1:505 MARTIN LUTHER KING JR AVENUE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33815-1527
Mailing Address - Country:US
Mailing Address - Phone:863-683-5567
Mailing Address - Fax:863-686-5814
Practice Address - Street 1:505 MARTIN LUTHER KING JR AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33815-1527
Practice Address - Country:US
Practice Address - Phone:863-683-5567
Practice Address - Fax:863-686-5814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0016779208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty