Healthcare Provider Details

I. General information

NPI: 1316930118
Provider Name (Legal Business Name): BRYAN DAVID BLAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 THORNTON RD
LITHIA SPRINGS GA
30122-2634
US

IV. Provider business mailing address

939 THORNTON RD
LITHIA SPRINGS GA
30122-2634
US

V. Phone/Fax

Practice location:
  • Phone: 770-948-5400
  • Fax: 770-948-4930
Mailing address:
  • Phone: 770-948-5400
  • Fax: 770-948-4930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number040613
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: