Provider Demographics
NPI:1922718014
Name:BLAKES, ROBERT TYLER
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:TYLER
Last Name:BLAKES
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:EMORY UNIVERSITY SCHOOL OF MEDICINE
Mailing Address - Street 2:100 WOODRUFF CIRCLE, SUITE P375
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:EMORY UNIVERSITY SCHOOL OF MEDICINE
Practice Address - Street 2:100 WOODRUFF CIRCLE, SUITE P375
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322
Practice Address - Country:US
Practice Address - Phone:404-727-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU6641458203OtherCIGNA