Healthcare Provider Details

I. General information

NPI: 1225340466
Provider Name (Legal Business Name): BLAKE HOFFMAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2010
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 M ST
BELLEVILLE KS
66935-2244
US

IV. Provider business mailing address

2510 K ST
BELLEVILLE KS
66935-2445
US

V. Phone/Fax

Practice location:
  • Phone: 402-469-8835
  • Fax:
Mailing address:
  • Phone: 402-469-8835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1343
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002497
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1870
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: