Provider Demographics
NPI:1023495470
Name:BLAKE, DIANA T (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:T
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 48089
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-8089
Mailing Address - Country:US
Mailing Address - Phone:706-389-3740
Mailing Address - Fax:706-389-3951
Practice Address - Street 1:2470 DANIELLS BRIDGE RD STE 231
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6188
Practice Address - Country:US
Practice Address - Phone:706-769-3362
Practice Address - Fax:706-769-5675
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA97760207R00000X
KY54149207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine