Provider Demographics
NPI:1750371886
Name:BURCHETT, BLAKE R (MD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:R
Last Name:BURCHETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 697
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-0697
Mailing Address - Country:US
Mailing Address - Phone:606-886-1173
Mailing Address - Fax:606-886-2193
Practice Address - Street 1:4851 KY ROUTE 321
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9113
Practice Address - Country:US
Practice Address - Phone:606-886-1173
Practice Address - Fax:606-886-2193
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24178207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64241789Medicaid
KYK040031OtherMEDICARE PTAN
KY1750371886OtherMEDICARE INDIVIDUAL NPI
KY1750371886OtherMEDICARE INDIVIDUAL NPI