Healthcare Provider Details

I. General information

NPI: 1659784338
Provider Name (Legal Business Name): BLAKE PUTMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 W CARO RD STE VI
CARO MI
48723-8209
US

IV. Provider business mailing address

1800 W CARO RD STE VI
CARO MI
48723-8209
US

V. Phone/Fax

Practice location:
  • Phone: 989-673-6144
  • Fax: 989-672-1800
Mailing address:
  • Phone: 989-673-6144
  • Fax: 989-672-1800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301105933
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: