Provider Demographics
NPI:1912903873
Name:BLAKE, W. PRESTON (MD)
Entity Type:Individual
Prefix:
First Name:W.
Middle Name:PRESTON
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 NW 26TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-2882
Mailing Address - Country:US
Mailing Address - Phone:352-317-8230
Mailing Address - Fax:
Practice Address - Street 1:4500 W NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2245
Practice Address - Country:US
Practice Address - Phone:352-336-6000
Practice Address - Fax:352-336-6029
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36563207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD50064Medicare UPIN
01277ZMedicare ID - Type Unspecified