Healthcare Provider Details

I. General information

NPI: 1083216949
Provider Name (Legal Business Name): BLAKE TAYLOR WALLACE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2020
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15601 N 28TH AVE STE 102
PHOENIX AZ
85053-4061
US

IV. Provider business mailing address

PO BOX 32611
BELFAST ME
04915-0219
US

V. Phone/Fax

Practice location:
  • Phone: 480-844-8218
  • Fax:
Mailing address:
  • Phone: 480-844-8218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD-001117
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: