Provider Demographics
NPI:1942200159
Name:PETERSON, BLAKE ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:ALLEN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 KEITH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-1351
Mailing Address - Country:US
Mailing Address - Phone:423-472-6517
Mailing Address - Fax:423-476-8578
Practice Address - Street 1:2020 KEITH ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-1351
Practice Address - Country:US
Practice Address - Phone:423-472-6517
Practice Address - Fax:423-476-8578
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1031152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3596680Medicare PIN
T61331Medicare UPIN
TN0271600001Medicare NSC