Healthcare Provider Details

I. General information

NPI: 1235510140
Provider Name (Legal Business Name): BLAKE RICHARD SHAFFER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

IV. Provider business mailing address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT208977
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0101261224
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: