Healthcare Provider Details

I. General information

NPI: 1932587722
Provider Name (Legal Business Name): JASON BLAKE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN ST
LEWISTON ME
04240-7041
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
BIDDEFORD ME
04005-9422
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-0111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO2895
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDO2895
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: