Healthcare Provider Details

I. General information

NPI: 1487040002
Provider Name (Legal Business Name): JOHNATHON BLAKE M.D., M.H.S.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10985 CODY ST STE 115
OVERLAND PARK KS
66210-1224
US

IV. Provider business mailing address

10985 CODY ST STE 115
OVERLAND PARK KS
66210-1224
US

V. Phone/Fax

Practice location:
  • Phone: 816-444-1777
  • Fax: 816-333-3277
Mailing address:
  • Phone: 816-444-1777
  • Fax: 816-333-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2019034662
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number04-42530
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: