Healthcare Provider Details

I. General information

NPI: 1891311403
Provider Name (Legal Business Name): BLAKE EVERETT VEST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6605 NANCY RIDGE DR # 200
SAN DIEGO CA
92121-2253
US

IV. Provider business mailing address

6605 NANCY RIDGE DR # 200
SAN DIEGO CA
92121-2253
US

V. Phone/Fax

Practice location:
  • Phone: 858-750-2983
  • Fax:
Mailing address:
  • Phone: 858-750-2983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberU8602
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberU8602
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: