Provider Demographics
NPI:1821468893
Name:BARTHOLOMEW, BLAKE WILLIAM
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:WILLIAM
Last Name:BARTHOLOMEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-3950
Mailing Address - Country:US
Mailing Address - Phone:772-473-1095
Mailing Address - Fax:
Practice Address - Street 1:1265 36TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6574
Practice Address - Country:US
Practice Address - Phone:772-567-6340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
FLPAT9118141363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered