Provider Demographics
NPI:1750655585
Name:BLAKE, ANNE M (MD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11550 GRANADA
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66206-2325
Mailing Address - Country:US
Mailing Address - Phone:913-451-7546
Mailing Address - Fax:
Practice Address - Street 1:11550 GRANADA ST
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1453
Practice Address - Country:US
Practice Address - Phone:913-451-7546
Practice Address - Fax:913-663-2411
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.059721207N00000X
OK29145207N00000X
KS04-37811207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP73000012Medicare PIN