Healthcare Provider Details

I. General information

NPI: 1518426980
Provider Name (Legal Business Name): BLAKE ANDREW VANDER WOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

IV. Provider business mailing address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-1440
  • Fax:
Mailing address:
  • Phone: 678-923-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number92047
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number92047
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: