Provider Demographics
NPI:1790769545
Name:BLAKER, BRAD A (DO)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:A
Last Name:BLAKER
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 1:50 N PERRY ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2217
Mailing Address - Country:US
Mailing Address - Phone:248-338-5327
Mailing Address - Fax:248-338-5129
Practice Address - Street 1:50 N PERRY ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2217
Practice Address - Country:US
Practice Address - Phone:248-338-5327
Practice Address - Fax:248-338-5129
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.016136207P00000X
MI5101013885207PE0004X
SC83418207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4504220Medicaid
MI4504220Medicaid
MIC56002039Medicare ID - Type Unspecified