Provider Demographics
NPI:1811963705
Name:BLAKE, SUSAN F (OD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:F
Last Name:BLAKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 LINWOOD AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-5624
Mailing Address - Country:US
Mailing Address - Phone:330-455-2348
Mailing Address - Fax:
Practice Address - Street 1:2216 LINCOLN WAY E
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-7062
Practice Address - Country:US
Practice Address - Phone:330-832-9966
Practice Address - Fax:330-832-6007
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5196152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH51108OtherDAVIS VISION
OH2601081Medicaid
OH311529091OtherUNITED HEALTH CARE
OH22683OtherNVA
OH27426OtherSPECTERA
OHOH5196OtherEYEMED
OH202699359OtherVSP
OH202699359OtherTRICARE
OH311529091OtherPCM
OHOH00213OtherVBA
OH202699359OtherTRICARE
OHOH00213OtherVBA