Healthcare Provider Details

I. General information

NPI: 1417953597
Provider Name (Legal Business Name): BLAKE C. LANDRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 W MILLER ST
ORLANDO FL
32806-2031
US

IV. Provider business mailing address

83 W MILLER ST
ORLANDO FL
32806-2031
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-5281
  • Fax: 321-843-2068
Mailing address:
  • Phone: 321-841-5281
  • Fax: 321-843-2068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number022661
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME174917
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number022661
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: