Healthcare Provider Details

I. General information

NPI: 1699272567
Provider Name (Legal Business Name): BLAKE ALLISTER LE GRAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 S HIGHLAND AVE STE 106
BRIARCLIFF MANOR NY
10510-2054
US

IV. Provider business mailing address

38 1/2 WOLDEN RD APT C2-8
OSSINING NY
10562-5312
US

V. Phone/Fax

Practice location:
  • Phone: 914-366-0015
  • Fax: 914-366-0012
Mailing address:
  • Phone: 347-992-0736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA11081300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number308910
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: