Healthcare Provider Details

I. General information

NPI: 1477545127
Provider Name (Legal Business Name): JEFFREY M BLAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 PRAIRIE LAKES BLVD N STE 110
NOBLESVILLE IN
46060-4370
US

IV. Provider business mailing address

14540 PRAIRIE LAKES BLVD N STE 110
NOBLESVILLE IN
46060-4370
US

V. Phone/Fax

Practice location:
  • Phone: 317-982-5222
  • Fax: 317-982-5223
Mailing address:
  • Phone: 317-982-5222
  • Fax: 317-982-5223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number01040057A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number01040057A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: