Provider Demographics
NPI:1972142545
Name:BLAKE, CONNOR (OD)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:BLAKE
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-233-6780
Practice Address - Street 1:494 GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-7351
Practice Address - Country:US
Practice Address - Phone:717-263-6186
Practice Address - Fax:717-263-6888
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2748152W00000X
PAOEG003850152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist