Provider Demographics
NPI:1801854898
Name:BLAKE, DONNEVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DONNEVAN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 S WEBSTER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-433-3640
Mailing Address - Fax:920-433-3716
Practice Address - Street 1:744 S WEBSTER AVE FL 2
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3640
Practice Address - Fax:920-433-3716
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52766-20207RC0000X
MI4301095491207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI002150206Medicare Oscar/Certification
WIP00878152Medicare Oscar/Certification
WIP00929201Medicare Oscar/Certification