Healthcare Provider Details

I. General information

NPI: 1518194687
Provider Name (Legal Business Name): SAMUEL S BLAKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 N 1100 E STE 101
AMERICAN FORK UT
84003-2940
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-492-2550
  • Fax: 801-492-2576
Mailing address:
  • Phone: 801-492-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60243907
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8631872-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: