Provider Demographics
NPI:1922076827
Name:BLAKE, DION ERICSON (IDC)
Entity Type:Individual
Prefix:MR
First Name:DION
Middle Name:ERICSON
Last Name:BLAKE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 NW 155TH TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1514
Mailing Address - Country:US
Mailing Address - Phone:954-804-8731
Mailing Address - Fax:
Practice Address - Street 1:USS JOHN L. HALL
Practice Address - Street 2:FPO AA 34091
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32228
Practice Address - Country:US
Practice Address - Phone:904-270-6541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman