Provider Demographics
NPI:1811938814
Name:BLAKE, DWIGHT D (MD)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:D
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4910 JONESBORO RD
Mailing Address - Street 2:BLDG. 700, STE. 1
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-2085
Mailing Address - Country:US
Mailing Address - Phone:770-964-7736
Mailing Address - Fax:770-306-1726
Practice Address - Street 1:4910 JONESBORO RD
Practice Address - Street 2:BLDG. 700, STE. 1
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-2085
Practice Address - Country:US
Practice Address - Phone:770-964-7736
Practice Address - Fax:770-306-1726
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-05-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA51117207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11SCGCMMedicare ID - Type Unspecified
D50824Medicare UPIN