Provider Demographics
NPI:1831113521
Name:BLAKE, JULIE ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:ANN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:105 STEVENS AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550
Mailing Address - Country:US
Mailing Address - Phone:914-371-7606
Mailing Address - Fax:914-371-7622
Practice Address - Street 1:105 STEVENS AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550
Practice Address - Country:US
Practice Address - Phone:914-371-7606
Practice Address - Fax:914-371-7622
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY222482-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02290559Medicaid
NYI26683Medicare UPIN
NY627Z31Medicare ID - Type Unspecified