Healthcare Provider Details

I. General information

NPI: 1205909447
Provider Name (Legal Business Name): BLAKE H HORIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N WABASH AVE UNIT 77F
CHICAGO IL
60611-3979
US

IV. Provider business mailing address

401 N WABASH AVE UNIT 77F
CHICAGO IL
60611-3979
US

V. Phone/Fax

Practice location:
  • Phone: 630-269-1459
  • Fax:
Mailing address:
  • Phone: 630-269-1459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036-090898
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036090898
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number036090898
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: